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Middle Range Theories Application to Nursing Research and Practice

Fourth Edition

Sandra J. Peterson, PhD, RN Professor Emerita Bethel University St. Paul, Minnesota Accreditation Partner NurseTim, Inc. Waconia, Minnesota

Timothy S. Bredow, PhD, RN, NP-C Professor Bethel University St. Paul, Minnesota

Acquisitions Editor: Christina C. Burns Product Development Editor: Helen Kogut Editorial Assistant: Cassie Berube Production Project Manager: Kim Cox Design Coordinator: Holly McLaughlin Illustration Coordinator: Jennifer Clements Manufacturing Coordinator: Karin Duffield Marketing Manager: Dean Karampelas Prepress Vendor: SPi Global

4th edition

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2004 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data Middle range theories : application to nursing research and practice / [edited by] Sandra J. Peterson, Timothy S. Bredow. — 4th edition. p. ; cm. Includes bibliographical references. ISBN 978-0-06-000044-8 I.Peterson, Sandra J., editor. II.Bredow, Timothy S., editor. [DNLM:1.Nursing Theory.2.Nursing Research.WY 86] RT84.5 610.7301—dc23

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I am grateful to be involved in the development of this book. I appreciate my colleague and partner in this project, all the amazing nurse scholars

who contributed, and the Wolters Kluwer staff who managed this publication journey. But most of all, I am so thankful for my family:

husband (Ray), 98-year-old mother (Margaret Cairns), son (Christopher), daughter-in-law (Alisa), grandchildren (Liam and Jane), and last but not

least (sorry for the cliché) daughter (Beth). They bring joy to my life. Sandra J. Peterson

I would like to dedicate this fourth edition to my family who provides me with the love and support to complete a project such as this: KTJBA, B, C,

Tiff, Ben, and also little Kata, Peper, Finley, and Maddy. And to all my students with the hope that in using this book, they will more fully

understand the relationships between theory, research, and evidence- based practice.

Timothy S. Bredow

Contributors to the Fourth Edition

Timothy S. Bredow, PhD, RN, NP-C Professor Bethel University St. Paul, Minnesota

Lisa Burkhart, PhD, RN, ANEF Associate Professor Marcella Niehoff School of Nursing Loyola University Chicago Chicago, Illinois

Georgene Eakes, EdD, RN Director, Clinical Education Vidant Medical Center Greenville, North Carolina

Audrey Gift, PhD, RN, FAAN Professor Emeritus Michigan State University, College of Nursing East Lansing, Michigan

Marion Good, PhD, FAAN Professor Emerita Frances Payne Bolton School of Nursing Lakewood, Ohio

Brian Goodroad, DNP, APRN,C-NP Associate Professor Metropolitan State University

St. Paul, Minnesota

Joan E. Haase, PhD, RN, FAAN Holmquist Professor of Pediatric Oncology Nursing Department of Clinical Nursing Science Co-Director, The RESPECT Signature Center at IUPUI Indiana University Indianapolis, Indiana

Sonya Hardin, PhD, RN, CCRN, ACNS-BC, NP-C Professor East Carolina University Greenville, North Carolina

Nancy S. Hogan, PhD, RN, FAAN Distinguished Professor Marcella Niehoff School of Nursing Loyola University Chicago Chicago, Illinois

Trine Klette, PhD Associate Professor Diakonova University College Oslo, Norway

Katharine Kolcaba, RN, MSN, PhD Associate Professor The University of Akron, Ursuline College Akron, Ohio

Elizabeth R. Lenz, PhD, RN Professor Emeritus The Ohio State University College of Nursing Columbus, Ohio

Marjorie McCullagh, PhD, RN, FAAOHN, FAAN Associate Professor and Director

Occupational Health Nursing Program University of Michigan School of Nursing Ann Arbor, Michigan

Renee Milligan, MD Term Professor, School of Nursing George Mason University Fairfax, Virginia

Sandra J. Peterson, PhD, RN Professor Emerita Bethel University St. Paul, Minnesota Accreditation Partner NurseTim, Inc. Waconia, Minnesota

Celeste R. Phillips, PhD, RN, CPON Assistant Professor Indiana University School of Nursing Indianapolis, Indiana

Mertie L. Potter, DNP, PMHNP-BC, PMHCNS-BC Professor MGH Institute of Health Professions Boston, Massachusetts Nurse Practitioner MVCA Nashua, New Hampshire

Linda C. Pugh, PhD, RNC, CNE, FAAN Director, Graduate Programs in Nursing York College of Pennsylvania York, Pennsylvania

Barbara Resnick, PhD, CRNP, FAAN, FAANP Professor Sonya Ziporkin Gershowitz Chair in Gerontology

University of Maryland, School of Nursing Baltimore, Maryland

Kristin E. Sandau, PhD, RN Professor of Nursing Bethel University St. Paul, Minnesota

Marjorie A. Schaffer, PhD, RN Professor Emerita Bethel University St. Paul, Minnesota

Ellen D. Schultz, PhD, RN, CHTP, AHN-BC Professor of Nursing Metropolitan State University St. Paul, Minnesota

Marjorie Webb, PhD(c), DNP, APRN, C-NP Associate Professor Metropolitan State University St. Paul, Minnesota

Danuta M. Wojnar, PhD, RN, MEd, FAAN Associate Professor Seattle University and Associate Dean for Undergraduate Programs Seattle, Washington

Contributors to the Third Edition Laurel Ash, DNP, CNP, RN Assistant Professor College of St. Scholastica Duluth, Minnesota

Georgene Eakes, EdD, RN Professor Emerita College of Nursing East Carolina University Director, Clinical Education Center for Learning and Performance Pitt County Memorial Hospital Greenville, North Carolina

Audrey Gift, PhD, RN, FAAN Professor Emeritus Michigan State University, College of Nursing East Lansing, Michigan

Marion Good, PhD, FAAN Professor Emerita, Frances Payne Bolton School of Nursing Case Western Reserve University Cleveland, Ohio Visiting Professor, Hong Kong University School of Nursing, 2010–2011

Joan E. Haase, PhD, RN, FAAN Holmquist Professor of Pediatric Oncology Nursing Department of Clinical Nursing ScienceCo-Director, The RESPECT Signature Center at IUPUI Indiana University Indianapolis, Indiana

Barbara Hoglund, EdD, MSN, RN, FNP-C Associate Professor of Nursing Bethel University St. Paul, Minnesota

Trine Klette, PhD Associate Professor Diakonova University College Oslo, Norway

Katharine Kolcaba, PhD, RN, MSN

Associate Professor, Emerita and Visiting Professor The University of Akron, Ursuline College Akron, Ohio

Elizabeth R. Lenz, PhD, RN, FAAN Dean, Professor College of Nursing The Ohio State University Columbus, Ohio

Marjorie McCullagh, PhD, RN, APHN-BC, COHN-S Assistant Professor and Director, Occupational Health Nursing Program School of Nursing University of Michigan Ann Arbor, Michigan

Renee Milligan, PhD, RN Associate Professor, School of Nursing Georgetown University Washington, District of Columbia

Mertie L. Potter, DNP, PMHNP-BC, PMHCNS-BC Professor MGH Institute of Health Professions Boston, Massachusetts Nurse Practitioner MVCA Nashua, New Hampshire

Linda C. Pugh, PhD, RNC, CNE, FAAN Director, Graduate Programs in Nursing York College of Pennsylvania York, Pennsylvania

Barbara Resnick, PhD, CRNP, FAAN, FAANP Professor Sonya Ziporkin Gershowitz Chair in Gerontology University of Maryland, School of Nursing

Baltimore, Maryland

Kristin E. Sandau, PhD, RN Professor of Nursing Bethel University St. Paul, Minnesota

Marjorie A. Schaffer, PhD, RN Professor Emerita Bethel University St. Paul, Minnesota

Ellen D. Schultz, PhD, RN, CHTP, AHN-BC Professor of Nursing Metropolitan State University St. Paul, Minnesota

Danuta M. Wojnar, PhD, RN, MEd, FAAN Associate Professor Seattle University and Associate Dean for Undergraduate Programs Seattle, Washington

Reviewers Kim Siarkowski Amer, MD Associate Professor DePaul University, School of Nursing Chicago, Illinois

Lori Bork, PhD, MSN, RN, CCRN Professor Dakota Wesleyan University Mitchell, South Dakota

Julie Brandy, PhD, RN, FNP-BC

Assistant Professor College of Nursing and Health Professions Valparaiso University Valparaiso, Indiana

Cynthia Brown, DNS, RN, AHN-BC, CNE Assistant Professor University of West Georgia Tanner Health System School of Nursing Carrollton, Georgia

Maria A. Connolly, PhD, CNE, ANEF, FCCM Professor of Nursing Adjunct Marcella Niehoff School of Nursing Loyola University Chicago Chicago, Illinois

Beth D. Crouch, MSN, RN, BS Assistant Professor of Nursing Milligan College Milligan College, Tennessee

Karen V. Duhamel, MSN, MS, RN Instructor of Nursing The University of Hartford West Hartford, Connecticut

Tresa Kaur Dusaj, PhD, RN-BC, CNE, CHSE, CTN-A Faculty Program Director Excelsior College Albany, New York

Michelle Edmonds, PhD, FNP-BC, CNE Professor of Nursing Jacksonville University Jacksonville, Florida

Susan Sweat Gunby, PhD, RN Professor Georgia Baptist College of Nursing Mercer University Atlanta, Georgia

Kathryn Van Dyke Hayes, PhD, RN, CNE Professor and Director of Graduate Nursing Programs Holy Family University Philadelphia, Pennsylvania

Phyllis Jeans, MSN, RN Assistant Professor Baptist College of Health Sciences Memphis, Tennessee

Melanie Kalman, PhD, RN Professor, College of Nursing Upstate Medical University Syracuse, New York

Theresa A. Kessler, PhD, RN, ACNS-BC, CNE Professor of Nursing and Kreft Endowed Chair for the Advancement of Nursing Science Valparaiso University Valparaiso, Indiana

Donna Koestler, EdD, MSN, RN Assistant Professor of Nursing Delta State University Cleveland, Mississippi

Regina Lederman, RN, BSN, MN Ed, MA, PhD, FAAN Professor, University of Texas Medical Branch at Galveston School of Nursing Graduate School of Biomedical Sciences Adjunct Professor, UT-Health Science Center School of Public Health

Galveston, Texas

Jerrilee LaMar, PhD, RN, CNE Associate Professor of Nursing Dunigan Family School of Nursing and Health Sciences University of Evansville Evansville, Indiana

Patricia A. Mattingly, MD Associate Professor of Nursing Keuka College Keuka Park, New York

Ann M. Mayo, DNSc, RN Professor of Nursing University of San Diego San Diego, California

Diane B. McNaughton, PhD, APHN-BC Associate Professor Rush University College of Nursing Chicago, Illinois

Bernita Missal, PhD, RN Professor Bethel University St. Paul, Minnesota

Aroha Page, PhD, (UCSF), MPhil(N), BA, BScN, Grad Dip Health Sci, RN, FRCNA Associate Professor Nipissing University North Bay, Ontario, Canada

Carole A. Pepa, PhD Professor Valparaiso University

Valparaiso, Indiana

Kathy Reavy, PhD, RN Professor Boise State University Boise, Idaho

Liz Seabrook, RN, MScN, DOHN BScN Professor Lambton College Sarnia, Ontario, Canada

Nuananong Seal, PhD, RN Professor UW–Milwaukee, College of Nursing Milwaukee, Wisconsin

Denice Kopchak Sheehan, PhD, RN Associate Professor Kent State University College of Nursing Kent, Ohio

Christie Shelton, PhD, RN, CNE Dean/Associate Professor Jacksonville State University Jacksonville, Alabama

Phyllis Skorga, PhD, RN, CCM Professor of Nursing Arkansas State University Jonesboro, Arkansas

Amy Rex Smith, PhD Professor Belhaven University Jackson, Mississippi

Julie Strunk, PhD, RN Professor James Madison University Harrisonburg, Virginia

Angela Thompson, DNP, BC-FNP, BC-WHNP Assistant Professor of Nursing Director FNP Program Wheeling Jesuit University Wheeling, West Virginia

Ching Eng H. Wang, PhD, APN, NP-C Associate Professor of Nursing North Park University Chicago, Illinois

Debra J. Bohlender Welch, PhD, RN-BC Assistant Professor, Post-Licensure (RN-BSN) Division Indiana Wesleyan University, School of Nursing Marion, Indiana

Preface

Middle range theories have understandably emerged as the focus of knowledge development in nursing with a broad acceptance of the need to develop middle range theories to support nursing practice.

There is a dynamic relationship between theory, research, and practice. Research is a source of theory development, and theory is a source of research questions. Theory is used to improve practice, and practice is used to generate, test, and refine theories. Basically, it is by testing the theories through research that the evidence for practice is generated. In this fourth edition, the change of the title to Middle Range Theories Application to Nursing Research and Practice better reflects this dynamic relationship with increased emphasis on applications of middle range theories to practice. We continue to hope that this edition can serve as a resource for nurse scholars and practitioners, making middle range theories more accessible and useful. The ultimate goal is the advancement of nursing as a profession and improving the quality of its practice.

With the increase in the number of middle range theories being developed, determining which to include in this edition is always a challenge. As for the previous editions, we reviewed published research and practice applications of theories. We also solicited input from practitioners. The goal was to identify those theories, though in the middle range of abstraction, are not particularly narrow in their possible applications. That process resulted in the addition of two middle range theories: the theory of change and the Experiential Theory of Spiritual Care in Practice.

Organization

Part I

Part I is devoted to an overview of the state of nursing's body of knowledge and the processes by which it is evaluated.

Chapter 1 introduces the interrelationship between nursing theory, research, and practice. In addition to a brief discussion of epistemology with a summary of Carper's conceptualization of nurses' ways of knowing, the majority of the chapter addresses the hierarchy of nursing knowledge. The emphasis, of course, is on the place of middle range theory within that hierarchy (i.e., paradigm, philosophy, conceptual framework, and theories). For each component of the hierarchy, the chapter includes a description of its nature, review of its development, a discussion of its contributions to nursing knowledge, consideration of controversies related to its nature or use, and examples of nurse scholars' work. The section devoted to middle range theories includes an expanded and updated table with multiple examples of middle range theories referenced. Also included is an expanded discussion of practice or situation-specific theories with a table that provides recent examples of this level of theory development.

Chapter 2 emphasizes the analysis and evaluation of middle range theories, including issues to consider in the selection of a middle range nursing theory for research purposes. This chapter also describes a brief evaluative process for theory analysis. Using this evaluation process, readers can compare and contrast their conclusions about the theory as presented in the chapter with those of a nurse scholar who has also used this evaluation process. The theory analysis exercises related to each chapter are available in the Student Resources located on (http://thepoint.lww.com/Peterson4e).

Parts II to VI Parts II to VI are devoted to specific middle range theories. The selected theories are labeled by their developers or by nurse scholars as middle range theories and are ones frequently cited in published nursing research or practice applications. Many of the chapters contain unique nursing theories; some are borrowed from related disciplines but are, nonetheless, useful to nursing. All theories in the text, however, have the intrinsic capability to be applied to nursing research and practice. They address a wide range of phenomena that allow the researcher to consider a variety of nursing research questions and uses in practice. The theories have been organized by categories to reflect a general focus of research questions or

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practice applications. The categories are not presented as absolute, but more as a guide to direct the user of the book to the theories that might be most relevant to their issue of interest.

Physiological—Pain: Balance of Analgesia and Side Effects; Unpleasant Symptoms Cognitive—Self-efficacy, Reasoned Action Emotional—Empathy, Chronic Sorrow, Experiential Theory of Spiritual Care in Practice Social—Social Support, Interpersonal Relations, Attachment Integrative—Modeling and Role-Modeling, Comfort, Heath-Related Quality of Life, Health Promotion, Deliberative Nursing Process, AACN Synergy Model, Resilience, Change

Special Features Each theory chapter provides the nurse researcher with a variety of tools. Key features include the following:

Definitions of Key Terms appear at the beginning of each chapter to define concepts and aid the reader's understanding of the theory. Using Middle Range Theories in Research boxes provide examples of how the theory has been used in published research. These have been updated and reformatted, using an outline based on the research process. Using Middle Range Theories in Practice boxes provide examples of theories applied to a specific clinical practice situation. They too have been reformatted so that the clinical issue and the use of the theory as a foundation for nursing intervention are clearly identified. Examples of Theory in Practice tables are included in each chapter. The headings on these tables are similar to the matrix used to critique research as a basis for evidence-based practice. Critical Thinking Exercises at the end of each chapter engage readers in analysis of the theory and its application to practice. Instruments are discussed in the chapters, with specific examples available in the Student Resources located on (http://thepoint.lww.com/Peterson4e).

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Resources on A variety of resources designed to enhance the teaching and learning

experience are available on (http://thePoint.lww.com/Peterson4e).

Analysis Exercises are provided for each theory chapter allowing readers to arrive at their own conclusions about the theory and then compare them to a nurse scholar's evaluation. By analyzing the particular theory with the detail suggested in Chapter 2, the student or reader becomes more intimately involved with the theory and is more likely to develop an understanding of the theory through the deeper evaluation of its constructs. This allows the person doing the analysis to grapple with the theory and to appreciate more fully its application to nursing research and ultimately to the building of the foundation of evidence-based practice for nursing. Web Resources provide links to pertinent websites to aid readers in their own research. Journal articles, related to each chapter, help further understanding of concepts and their applications.

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Acknowledgments

There is a sense of accomplishment that accompanies the completion of a project such as this text. We would have never been able to experience that rather pleasant sensation without the significant involvement of many others. The quality of the scholarship of the chapter authors will be evident to all those who read the text. Their willingness to invest themselves in this project, consistently providing what was needed in a timely fashion, is much appreciated. Those who completed the Analysis of Theory, that is available on , have added what we believe will be a useful resource to readers, enabling them to clarify their understanding of the theories.

The staff at Wolters Kluwer was invaluable. Christina C. Burns, Senior Acquisitions Editor, continued to see this book as a contribution to the body of nursing literature. Helen Kogut, Senior Product Development Editor, expertly coordinated the project. We would also like to thank Eileen Wolfberg, Development Editor, for shepherding this project to completion. And finally, we are profoundly grateful for the forbearance of our family and friends (especially husband, Ray Peterson, and wife, Kate Bredow). They helped us have “lives” beyond the scope of completing this book.

Contents

PART I Overview of Theory

1 Introduction to the Nature of Nursing Knowledge Sandra J. Peterson Philosophy Metaparadigm and Paradigms Conceptual Models Theory: General Issues Grand Theory Middle Range Theory Practice Theory/Micro Theory/Situation-Specific Theory Summary

2 Analysis, Evaluation, and Selection of a Middle Range Nursing Theory

Timothy S. Bredow Historical Background Theory Analysis Theory Evaluation Selecting a Theory for Nursing Research Middle Range Theory Evaluation Process

Part II Middle Range Theories: Physiological

3 Pain: A Balance Between Analgesia and Side Effects Marion Good Historical Background Definition of Theory Concepts Description of the Theory of Pain: A Balance Between Analgesia and Side Effects Applications of the Theory Use of the Theory in Practice

Summary

4 Unpleasant Symptoms Elizabeth R. Lenz, Linda C. Pugh, Renee Milligan, and Audrey Gift Historical Background The Theory of Unpleasant Symptoms Description of the Theory of Unpleasant Symptoms Models That Expand or Modify the Theory of Unpleasant Symptoms Assessment of Symptoms Instruments Used in Empirical Testing Summary

Part III Middle Range Theories: Psychological

5 Self-Efficacy Barbara Resnick Historical Background Definition of Theory Concepts Relationships Among the Concepts: The Mode Application of the Theory in Research Application of the Theory in Practice Summary

6 Chronic Sorrow Georgene Eakes Historical Background Current Research on Chronic Sorrow Middle Range Nursing Theory of Chronic Sorrow Research Applications of Chronic Sorrow NCRCS Chronic Sorrow Instrument Development Summary

7 Spiritual Care in Nursing Practice (SCiNP) Lisa Burkhart and Nancy S. Hogan Historical Background Empirical Development of the Spiritual Care in Nursing Practice Theory Definition of Theory Concepts Instruments Used in Empirical Testing

Application of the Theory in Practice Application of the Theory in Research Summary

Part IV Middle Range Theories: Social

8 Social Support Marjorie A. Schaffer Historical Background Definition of Theory Concepts Application of the Theory in Practice Application of the Theory in Research Challenges to Social Support Theory Development and Research Summary

9 Caring Danuta M. Wojnar Historical Background Theory Development Definitions of Theory Concepts Description of the Theory of Caring Application of the Theory in Research Application of the Theory in Practice Summary

10 Interpersonal Relations Sandra J. Peterson Historical Background Definitions of Theory Concepts Description of Theory of Interpersonal Relations Applications of the Theory: Research Applications of the Theory: Practice Applications of the Theory: Theory and Model Development Summary

11 Attachment Trine Klette and Sandra J. Peterson Historical Background Description of Attachment Theory

Definition of Key Concepts Internal Working Models Patterns of Attachment Attachment as a Basic Need Attachment and Care Attachment and Health Development and Change Applications of Attachment Theory: Research Applications of Theory: Practice Further Research Summary

Part V Middle Range Theories: Integrative

12 Modeling and Role-Modeling Ellen D. Schultz Historical Background Expanded Definitions of Modeling and Role-Modeling Concepts Description of the Theory of Modeling and Role-Modeling Applications of the Theory in Research Instruments Used in Empirical Testing Application of the Theory in Practice Outcome Summary

13 Comfort Katharine Kolcaba Historical Background Definitions of Theory Concepts Description of Theory: Major Components and Their Relationships Research Applications for the Theory of Comfort Instruments Used in Empirical Testing Summary

14 Health-Related Quality of Life Kristin E. Sandau, Timothy S. Bredow, and Sandra J. Peterson Historical Background Definition of Theory Concepts Description of the Theory of Quality of Life and Health-Related

Quality of Life Application of the Theory in Research Instruments Used in Empirical Testing Health-Related Quality of Life as an Outcome Measure in Nursing Summary

15 Health Promotion Marjorie McCullagh Historical Background Pender's Definition of Health Description of the Health Promotion Model Implications of the Model for Clinical Practice Summary

16 Deliberative Nursing Process Mertie L. Potter Historical Background Definition of Theory Concepts Description of the Theory of Deliberative Nursing Process Applications of the Theory Instruments Used in Empirical Testing Conclusion Summary

17 Resilience Joan E. Haase and Celeste R. Phillips Historical Background and Current Perspectives Definition of Resilience and Concepts Description of Resilience: the Theory Application of a Theory: The Resilience in Illness Model Instruments Used in Empirical Testing of Resilience Summary

18 Planned Change Brian Goodroad, Marjorie Webb, and Timothy S. Bredow Historical Background Definition of Theory Concepts The Health Belief Model Theory of Planned Behavior

Transtheoretical Model Organizational Change Theories Summary

19 The AACN Synergy Model Sonya Hardin Historical Background Description of the Theory of Synergy Model Use of the Theory in a System Summary

Appendix Instruments Burke/Eakes Chronic Sorrow Assessment Tool© General Comfort Questionnaire Comfort Behaviors Checklist Scoring of the Behaviors Checklist Pediatric Asthma Quality of Life Questionnaire With Standardized Activities (PAQLQ[S])

Index

PART I Overview of Theory

1 Introduction to the Nature of Nursing Knowledge

Sandra J. Peterson

Definition of Key Terms

Concept Symbolic representation of a phenomenon or set of phenomena

Conceptual model “Set of abstract and general concepts and the propositions” (Fawcett, 1997, pp. 13–14) that represents a phenomenon of interest

Deduction Reasoning from the general or universal to the particular or specific

Discipline A field or branch of knowledge that involves research

Domain Related components or items that reflect the unified subject matter of a discipline

Empiricism A philosophical theory of knowledge acquisition through experience, observation, and experiment

Ethics A branch of philosophy concerned with moral principles

Epistemology A branch of philosophy concerned with the sources of knowledge of truth and the methods used to acquire it

Induction Reasoning from the individual or particular to the general or universal

Logic A branch of philosophy concerned with sound reasoning and validity of thought

Logical positivism Philosophical perspective that espouses logic, objectivity, falseness/truth, observable and operationally defined concepts, and prediction

Metaparadigm Global concepts specific to a discipline that are philosophically neutral and stable

Metaphysics A branch of philosophy concerned with the study of ultimate cause and underlying nature of that which exists

Metatheory A philosophical theory about theories, concerned with “logical and methodological foundations of a discipline” (Beckstrand, 1986, p. 503. Examines “how theory affects and is affected by research and practice within nursing, and philosophy and politics outside nursing” (McKenna, 1997, p. 92).

Ontology Examination of the nature of being or reality

Paradigm A worldview, a common philosophical orientation, that serves to define the nature of a discipline

Phenomenon A designation of an aspect of reality

Philosophy (1) A set of beliefs or values; (2) science concerned with the study of reality and the nature of being. Composed of but not limited to aesthetics, epistemology, ethics, logic, and metaphysics

Science A systematized body of knowledge that has as its main purpose the discovery of “truths about the world” (Jacox, 1974, p. 4), confirmed through empirical investigation

Theory “Set of interrelated concepts, based on assumption, woven together through a set of propositional statements” (Fitzpatrick, 1997, p. 37) used to provide a perspective on reality

Introduction Nurses are fundamentally knowledge workers (Porter-O'Grady, 2003). Because “nurses rely on extensive clinical information and highly specialized knowledge to implement and evaluate the processes and outcomes of their clinical decision making” (Snyder-Halpern, Corcoran- Perry, & Narayan, 2001, Nurses as Knowledge Workers, para. 1), this title seems quite appropriate. What then is knowledge? What are its sources? How is the quality of the knowledge determined? How can knowledge be translated into practical applications that improve patient outcomes? Answering these questions serves to advance the discipline of nursing and improve the way it is practiced.

Attempts to answer the question of what constitutes the nature of knowledge have been primarily the domain of the branch of philosophy referred to as epistemology. Traditionally, knowledge has been defined as a belief that was justified as true with absolute certainty. This definition requires that for knowledge to exist, it must be believed; if not believed, something cannot be known. It also must be true; if not true even if well justified and believed, it cannot be considered knowledge. Finally, there must be sound reasons for the belief; if there are no sound reasons for a belief, it would be more a probable opinion or lucky guess than knowledge. There is not universal agreement about the nature of a sound reason or adequate evidence for a belief.

There are multiple epistemological theories to describe the nature of knowledge and explain its sources or how something can be known. Examples of epistemological theories include idealism, pragmatism, rationalism, and relativism. The theory of empiricism, most closely associated with natural science, considers knowledge to be a result of human experience. Ideas and theories can then be tested against reality and accepted or rejected on the basis of how well they are congruent with observable facts. This falls within the domain of research.

Theory, research, and practice are inextricably linked in the ways nursing knowledge is developed and used. “In 2001, the Institute of Medicine challenged all health care professionals to decrease variation in practice through adoption of interventions based on best evidence to

improve patients' outcomes” (Flynn Makic, Rauen, Watson, & Will Poteet, 2014, p. 1). Theory and research are sources of the evidence that improve the quality of nursing care, as noted in the 2012 American Association of Critical-Care Nurses Levels of Evidence. In their hierarchy, the synthesis and analysis of multiple research studies were identified as the highest level of experimental evidence; theories were identified at a lower level but directly useful as recommendations (Peterson et al., 2014). The relationship between theory, research, and practice is actually a reciprocal one as illustrated in Figure 1.1. For instance, as noted in the figure, the practice environment is not only where theory and research are used but also a source of research questions and data to answer those questions as well as the inspiration for many nursing theories. Though the relationship among the three is considered reciprocal, theory and research should ultimately serve the needs of practice.

Figure 1.1 Reciprocal relationships between theory, research, and practice.

Though most discussions of evidence focus on empirical knowledge, there are other ways to conceptualize the knowledge base needed to practice nursing. Carper (1978) has proposed four distinct patterns that she called ways of knowing: (1) empirics, the science of nursing; (2) aesthetics, the art of nursing; (3) personal knowing, the intra- and interpersonal nature of nursing; and (4) ethics, the moral component of nursing. These patterns expand the notion of what constitutes the knowledge nurses need to

practice. Empirical knowing is positivistic science, which means that it is

logically determined and based on observable phenomenon. It is knowledge that is systematically organized into general laws and theories that serve to describe, explain, and/or predict the phenomena of interest to nursing (Carper, 1978). The sources of empirical knowledge are research and theory and model development. There is no coherent conceptual structure that is generally accepted as nursing's scientific paradigm, which can lead to the possibility of a confusing and sometimes conflicting knowledge base. For the practicing nurse, empirical knowledge must always be interpreted within the context of specific clinical situations.

Aesthetic knowing is a process of “perceiving or grasping the nature of a clinical situation; interpreting this information in order to understand its meaning for those involved, while envisioning desired outcomes in order to respond with appropriate skilled action; and subsequently reflecting on whether the outcomes were effectively achieved” (Johns, 1995, Aesthetics, para. 1). Aesthetic knowing comes from the nurse's ability to grasp and interpret the meaning of a situation. It makes use of the nurse's intuition and empathy. This type of knowing also involves the nurse's skills in imagining a desired and practical outcome in the actual situation and responding based on an interpretation of the whole situation, analyzing the interrelationships of its various aspects. Unfortunately, aesthetic knowing cannot be articulated; it is not transferable to others. It is based solely on the skill of the nurse in a specific situation. This type of knowing has also been criticized for the role of empathy in nursing knowledge acquisition. White (2004) claims that empathy is a psychological phenomenon that has been uncritically adopted by nursing.

Personal knowing is knowledge of the concrete, individual self; it is not knowledge about the self. It involves encountering and actualizing the self in a way that enables the nurse to transcend the notion of other individuals as objects; but instead, the nurse engages with others in authentic personal relationships. The type of knowing and the nature of these relationships result in an increasing willingness to accept ambiguity, vagueness, and discrepancy in oneself and others. Personal knowing is the basis of the therapeutic use of self in the nurse–patient relationship. Reflection is the primary means by which personal knowing occurs. It involves three interrelated factors:

1. The perception of the self's feelings and prejudices within the situation

2. The management of the self's feelings and prejudices in order to respond appropriately [to the other]

3. Managing anxiety and sustaining the self (Johns, 1995, The personal way of knowing, para. 2)

Like aesthetic knowing, personal knowing cannot be described; it can only be actualized. In order to escape the problem of self-delusion, there is a need for individual reflection that is informed by the responses of others. But data about self from others can also be problematic in that it can be misperceived. In addition, personal knowing presents the nurse with a dilemma; personal knowledge needs to be integrated or reconciled with the professional responsibility of the nurse to manipulate the environment in order to work toward a desired health outcome (Carper, 1978, p. 19). Personal knowing, of all the ways of knowing, is the most difficult to teach and to master (White, 2004, p. 253).

Ethical knowing is knowledge of what is right or wrong and the commitment to act on the basis of that knowledge. It involves “judgments of moral value in relation to motives, intentions and traits of character” (Carper, 1978, p. 20) and focuses on obligations, on what ought to be done related to those judgments. Sources of ethical knowledge include the nursing's ethical codes and professional standards. It is also important for the nurse to have an understanding of different philosophical positions as to what is considered good and what is identified as an obligation. Consideration of the philosophical positions can also create confusion since ethical theories of what is good and what constitutes an obligation can conflict. For instance, the teleological perceptive considers what is good on the basis of its production of the greatest good for the greatest number (consequentialism), whereas the deontological perspective identifies good not by the consequences of actions but by the nature of the actions themselves.

Each of the ways of knowing represents a necessary but incomplete representation of the discipline of nursing. There is also an inherent interrelationship between the four patterns. For instance, aesthetic knowing would require empirical knowledge in order to envision what the desired and practical outcomes in a situation might be and what would constitute valid means of helping to bring about that desired outcome. Although Carper acknowledged that the patterns were interdependent, she has been criticized for failing to integrate the patterns and not specifying exactly how they are related (Risjord, 2010). With an acknowledgement of the

contributions of all the ways of knowing to the practice of nursing, this book focuses on empirical knowing in the broadest sense, on nursing theories, especially those that are considered middle range.

Two claims can be made about the state of empirical knowledge in nursing—it exists in varying degrees of abstraction, and it is characterized by a lack of consistency in the use of its language. Fawcett (2005a) refers to a structural “holarchy” of contemporary nursing knowledge to establish the relationships between the various components that constitute nursing's body of knowledge. In her early writings, Fawcett identified four components arranged from most abstract to most concrete in the following order: philosophy/paradigm, conceptual model, and theories. Recently, she added a fifth and most concrete component, empirical indicator, which refers to “a very concrete and specific real world proxy or substitute for a middle-range theory concept; an actual instrument, experimental condition, or procedure that is used to observe or measure a middle-range theory concept” (p. 36). Figure 1.2 provides a representation of this holarchy.

Figure 1.2 Holarchy of nursing knowledge.

The types of theories available to nurses also exist on a continuum from most abstract to most concrete, with grand theories identified as most abstract, practice- or situation-specific theories as most concrete, and middle range theories in the logical middle. There are few components in the holarchy or hierarchy that appear consistently in the literature with a

single label. The terms conceptual models, conceptual frameworks, and theories are sometimes used interchangeably. The terms grand theory, macro theory, and general theory all refer to the same level of theory development. The literature also provides examples of the terms conceptual model and middle range theory used as equivalent terms.

This chapter addresses each component of the conceptual hierarchy or continuum, with special emphasis on middle range theories. The nature of the component, its development, its contributions to nursing's body of knowledge, and the debates engaged in by nurses in relation to the component are considered.

Philosophy In the nursing literature, the term philosophy is used in two distinct ways, as a unique discipline and as a set of beliefs of a separate discipline, for example, nursing. As a discipline, it is often defined by its main branches: metaphysics, epistemology, ethics, logic, and aesthetics. Philosophy is primarily concerned with the nature of being, the meaning and purpose of life, and the theory and limits of knowledge, whereas science is more concerned with causality (Silva, 1997). Philosophy is considered unorganized and noninvestigative, more dependent on common experience, in contrast to science, which is considered investigative and dependent on special experience (Simmons, 1992, pp. 16–17).

For a discipline, philosophies represent its beliefs and values and its mind-set or worldview. They function “to communicate what the members of a discipline believe to be true in relation to the phenomena of interest to that discipline, what they believe about how the knowledge about those phenomena should be developed and what they value with regard to their actions and practices” (Fawcett, 2005, p. 34). Like other disciplines, nursing has reflected and is reflecting the modern and postmodern, and some would include neomodern thinking or worldview of its time.

Development Philosophies emerge as a reflection on the issues of interest to philosophers, primarily logic, ethics, aesthetics, metaphysics, and

epistemology. In the 20th and 21st centuries, these reflections or philosophies have been often characterized as either modern or postmodern perspectives. Although modernism and postmodernism do not represent singular philosophies but, rather, a collection of philosophies (Burbules, n.d, para. 2), each possesses commonly occurring themes that can serve as points of contrast. The most basic comparison between the schools of thinking is in their perspectives on metanarratives, defined as efforts to offer “general and encompassing accounts of truth, value, and reality” (Burbules, n.d, para. 5). In modernism, the metanarratives are a primary concern. In postmodernism, metanarratives are dismissed. This dismissal is not necessarily rejection or denial but instead doubt and uncertainty about what metanarratives have to offer. These schools of thought also differ in their view of the nature of problems. In modern thinking, problems are to be solved. In postmodern thinking, they are to be deconstructed, requiring a disassembling of the metanarratives that are entangled in values and beliefs that fail to reveal reality or liberate the oppressed (Reed, 1995, Historical Background: Modernism and Postmodernism, para. 3). Reed (1995) also identifies distinctions in epistemology: modernism, concerned with the truth of findings, and postmodernism, concerned with the usefulness of findings. She also suggests a neomodernism perspective, which rejects modernism's logical positivism and postmodernism's radical relativism and lack of coherent vision to focus instead on a plurality of realistic visions of a possible future (Bisk, nd). Reed's neomodern perspective for nursing embraces the metanarratives of health and the processes of healing but integrates them with the postmodern assumptions that knowledge is value-laden and that context is critical in order to achieve the desired future.

A schema proposed by Lerner (1986), which considered the nature of human development, is useful in categorizing nursing philosophies. Three worldviews of most interest are:

1. Mechanistic, in which the machine is the metaphor for the human being. The whole is equal to the sum of the parts, and the goal is a return to equilibrium.

2. Organistic, in which a biologic organism composed of complex interrelated parts is the basic metaphor. The organism is active in a passive environment. Change is probable, goal-directed, and developmental.

3. Developmental–contextual, in which historical events are the metaphor. The individual is immersed in a dynamic context. Change

in the person and the environment is ongoing, irreversible, innovative, and developmental. Chaos and conflict are an energy source for change (Reed, 1995).

Uses Kikuchi (1992) claims that “without an understanding of philosophy in nursing there can be no science of nursing” (p. 45). The branches of philosophy suggest a set of questions with relevance to nursing. For instance, ethical nursing questions would be concerned with what is good to do and to seek to attain nursing's goals (Kikuchi, 1992). Epistemological questions would focus on the structure, scope, and reliability of nursing's knowledge, and ontological questions would relate to the meaning of nurses' and clients' realities (Silva, Sorrell, & Sorrell, 1995). But these important questions are ones that are best addressed through philosophical inquiry. Philosophy makes a significant contribution to nursing's theories, research, and practice as demonstrated in Table 1.1.

Table 1.1 Contributions of Philosophy to Nursing

The contribution philosophy makes to theory cannot be overestimated. “… All nursing theory or research derives from or leads to philosophy” (Phillips, 1992, p. 49). The conceptual clarification specified by the philosopher of science helps the theorist generate better theories, and the speculation engaged in by the philosopher of science can also suggest the

theories of the future (Smart, 1968, p. 17). Analysis of a theory reveals the underlying assumptions and worldview (philosophy). By considering these philosophical statements, nurses can determine the fit between the values and beliefs expressed through the theory and their own. This enables researchers and practitioners to select theories that are philosophically congruent with their own perspectives on nursing. Therefore, philosophy plays a critical role in the formulation of questions important to nursing, the consideration of research methods, and the development of theories and their analysis and use in practice.

Controversy The controversy about nursing philosophy centers on the belief systems that exist within the discipline of nursing and the relative value of unity or diversity in nursing thought. Roach (1992) argues that philosophical inquiry in nursing is the pursuit of universal, transcendent principles and suggests metaphysics as the basis for nursing's unity. Others refer to this search for a coherent philosophical foundation in nursing as a pursuit of unity in diversity of thought (Newman, 2002; Phillips, 1992). The diversity of perspectives represented in the variety of existing nursing models requires philosophical inquiry as a means of determining underlying philosophical themes and patterns. This search for the unitary nature of phenomena of concern to nursing will lead to the recognition of core beliefs:

A holistic view of persons (Phillips, 1992; Roach, 1992) A commitment to caring as an expression of the human mode of being (Newman, Sime, & Corcoran-Perry, 1996; Roach, 1992) A perspective on education that acknowledges the unity of mind– body–spirit and recognition of the universe of knowledge that is necessary to achieve and makes a contribution to human understanding (Roach, 1992) A view of humans in relationship, with awareness of ethical–moral bonds (Roach, 1992).

Though diversity may result in confusion and lack of clarity in nursing's theory-development and research agenda, others believe that a philosophy that represents the worldview of all nurse scientists would be diluted to the point of becoming meaningless and useless (Landreneau, 2002). Diversity

of philosophies may be viewed as a more accurate representation of reality, a perspective consistent with postmodern thinking, and may have the potential of stimulating greater creativity and variety in the development of nursing models and theories.

Metaparadigm and Paradigms The terms metaparadigm and paradigm are frequently found in the nursing literature. A metaparadigm is considered the most abstract set of concepts of the discipline and serves to determine what constitutes its unique domain. Similar to philosophies, paradigms are an abstract means of expressing and organizing a discipline's knowledge. The metaparadigm of a discipline is considered global, philosophically neutral, and fairly stable.

Paradigms are distinguished from a metaparadigm in that they are considered discipline-specific, philosophical, and mutable. “Under the umbrella of the metaparadigm, there are supposed to be several paradigms” (Risjord, 2010, p. 100).

Metaparadigm Metaparadigm is defined as the global concepts specific to a discipline and the global propositions that define and relate the concepts (Fawcett, 2000, p. 4). A metaparadigm transcends all specific philosophical or paradigmatic orientations and serves to unify them. There are four requirements for the metaparadigm of any discipline: (1) a domain distinctive from other disciplines, (2) inclusive of all phenomena of interest to the discipline in a parsimonious way, (3) perspective neutral, and (4) international in scope and substance (Fawcett, 1996, p. 94). The metaparadigm is composed of several domains, often referred to as a typology. These domains are a classification system to identify the constructs or phenomena that are the focus of nursing. Several nursing metaparadigms have been suggested. For instance, Kim (2000) suggested a four-domain typology consisting of client, client–nurse, practice, and environment. The client domain is concerned with only those phenomena that pertain to the client. The client–nurse domain focuses on the phenomena that emerge from nurse–client interactions. The practice

domain refers to what nurses do as a professional. The environment domain is composed of physical, social, and symbolic components of the client's external world, both past and present. The four domain typology most frequently cited in nursing literature includes man/person, health, society/environment, and nursing (Fawcett, 1978; Yura & Torres, 1975). The metaparadigm described by Fawcett is also composed of four nonrelational and four relational propositions. The nonrelational propositions provide the definitions of the four domains and the relational propositions describe the linkages between the domains. See Table 1.2 for an overview of these propositions.

Table 1.2 Fawcett's Relational and Nonrelational Propositions of Metaparadigm

Development A metaparadigm is not so much constructed as it is identified. This

identification process occurs through the analysis of the recurring themes of nursing's theories (Sarter, 1988). This analysis is philosophical in nature and allows for recognition of the “common and coherent philosophical orientation” (p. 52) of the discipline of nursing.

Uses Metaparadigms, or in Kim's (1983) words, a typology, are “boundary- maintaining devices” (p. 19) and as such help delineate nursing's frame of reference. The primary purpose then is to provide a means of focusing on that which is inherently nursing and marginalizing that which is not. This enables nurse practitioners, theorists, and researchers to concentrate their energies on the business of nursing. In addition, the metaparadigm is used for the purpose of analysis, a framework for comparing the perspectives of various nursing theorists (Fawcett, 2000; Fitzpatrick & Whall, 1983; Kim, 1983). For instance, Fitzpatrick and Whall noted that Levine defined health as wholeness, whereas Johnson found health to be a moving state of equilibrium.

Controversy By definition, a discipline possesses only one metaparadigm. The controversy involves what that metaparadigm should be. Fawcett (2005) critiqued nine other paradigms using the criteria of distinctiveness, inclusiveness, neutrality, and internationality. The paradigms suggested by Newman; Conway; Kim; Meleis; King; Newman, Sime, and Corcoran- Perry; Malloch, Martinez, Nelson, Predeger, Speakman, Stienbinder, and Tracy; Parse; and Leininger/Watson all failed to meet one or more of the stated criteria. Fawcett's most common criticism was failure of the paradigms to meet the criterion of inclusion. For example, Kim (1983) did not address health; King (1984) eliminated environment and nursing; and Newman and associates (1996) failed to include environment. Obviously, nursing is still in search of a commonly shared metaparadigm, and further philosophical analysis is required to arrive at this metaparadigm.

The metaparadigm proposed by Fawcett has also received criticism. It was faulted for using outdated language (Fawcett, 2003), being oriented to a particular paradigm (Fawcett, 2003), providing a limited perspective of the domains (Malone, 2005), and reflecting a cultural bias (Kao, Reeder,

Hsu, & Cheng, 2006). Leininger criticized use of the term person as being too individualistic and Fawcett now proposes using the term persons (Fawcett, 2003, p. 273). Malone (2005) found the conceptualization of the domain, environment, to be underdeveloped; she believed greater emphasis is needed on the policy environment. The Western orientation of the metaparadigm is also criticized. In light of the fact that nursing is a global enterprise, this criticism seems warranted. Kao et al. (2006) provided definitions of each of the four domains from the perspective of Chinese philosophies. For instance, the concept person can be defined in part as a social being engaged in ethical relationships, relationships governed by certain rules (p. 93). Fawcett (1996) believes that the nursing metaparadigm that she proposed is the final conceptualization for the discipline, though likely to change. “Indeed, it is anticipated that modifications in the metaparadigm concepts and propositions will be offered as the discipline of nursing evolves” (p. 95). Recent nursing literature reveals only limited consideration of the discipline's metaparadigm.

Paradigms Kuhn introduced the term paradigm and stimulated interest in its use as a method of defining and analyzing the nature of a discipline. He also acknowledged the existence of multiple and conflicting definitions of the term (Kuhn, 1977, p. 294). Kuhn (1996) included the following as the components of paradigms or, as he later referred to them, disciplinary matrices: (1) symbolic generalizations; the laws accepted by a scientific community and the language used to express them; (2) shared commitments to beliefs in particular models; shared beliefs about and commitment to the prevailing theories of the discipline and the motivation and methods used to create and test them; (3) values; shared values that serve to identify what is significant or meaningful to the scientific community; and (4) exemplars; the specific problems to be solved and the methods used to solve them. Guba (1990) suggested a means of differentiating paradigms. Paradigms can be distinguished by the answers to three questions:

1. Ontological: What is the nature of the “knowable”? Or, what is the nature of “reality”?

2. Epistemological: What is the nature of the relationship between the

knower (the inquirer) and the known (or knowable)? 3. Methodological: How should the inquirer go about finding out

knowledge (p. 18)?

The components identified by Kuhn and the answers to the questions posed by Guba express the nature of existing paradigms. Before a paradigm is identified, the facts generated by the discipline and the methods used to generate them are disorganized. The discipline is considered to be in a preparadigm stage of development.

Development Paradigms emerge when they are recognized as a dominant way of thinking about the discipline by its scientific community. Kuhn (1996) refers to the emergence of a new paradigm as a revolution in which the new paradigm replaces an older one. “…scientific revolutions are inaugurated by a growing sense, again often restricted to a narrow subdivision of the scientific community, that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way” (Kuhn, 1996, p. 92).

Shapere (1980) criticized the notion of revolution, noting that scientific advances can be cumulative in that later sciences build on what existed earlier. This is a more evolutionary perspective on paradigm development. Integration has also been proposed as a form of paradigm development. This form of paradigm development describes a pattern in progress that is created “through accommodation, refinement, and collaboration between thoughts, ideas, and individuals” (Meleis, 1997, p. 80). Meleis believes paradigm development in nursing is characterized by this approach.

There are multiple paradigms and systems of classifying the paradigms used to express the worldview of the discipline of nursing. Three commonly cited paradigms are those of Parse (1987), Fawcett (1995), and Newman et al. (1996). Of these three, the most frequently cited in the nursing literature is Parse's. Each focuses on different constructs or domains of nursing's metaparadigm: Parse on the relationship between persons and their environments; Fawcett on persons (more recently referred to as human beings [2013]); and Newman, Sime, and Corcoran- Perry on caring and health. Table 1.3 summarizes these paradigms.

Table 1.3 Examples of Nursing's Paradigmatic Schemes

Note: These philosophical schemes are also referred to as paradigms.

There are a number of similarities in the paradigms proposed by Parse, Newman, et al., and Fawcett. The totality, particulate–deterministic, and reaction paradigms share features in common as do the simultaneity, unitary, and simultaneous action paradigms.

There are a number of other classifications of paradigms identified in the literature to describe actual or preferred perspectives of nursing. Many seem to be a renaming of or very similar to the conceptualizations of previously identified paradigms, particularly Parse's totality and simultaneity. For instance, Monti and Tingen (1999) suggest empiricism and interpretative; Guiliano, Tyer–Viola, and Lopez (2005) identify received view and perceived view; Weaver and Olson (2006) propose positivism/postpositivism and interpretive; and Pilkington and Mitchell (1999, 2003) refer to natural science and human science.

Uses One function of a paradigm is to identify the boundary or limits of the subject matter of concern to a discipline (Kim, 1989). A paradigm also provides a summary of the intellectual and social purposes of the discipline. It provides the “perspective with which essential phenomena of concern are conceptualized” (Kim, 1997, p. 32). A paradigm is considered

to represent a worldview, “a coherent and common philosophical orientation” (Sarter, 1988, p. 52).

Therefore, paradigms can provide the frames of reference for the construction of nursing theory and the use of nursing and nonnursing theories in nursing research. “The paradigm determines the way in which scientists make sense of the world. Therefore, without it, there is nothing about which to construct theories” (Antiognoli-Toland, 1999, p. 39). Multiple theories generally emerge from a single paradigm.

Paradigms also are important to nursing researchers. Researchers need to be assured that what is being studied will contribute to the body of nursing knowledge. By providing definitions of the discipline's boundaries, paradigms provide researchers with a nursing context for their research. Paradigms more specifically suggest the types of research questions that need to be addressed and appropriate methods used to answer the questions (Guiliano et al., 2005). Thus, nursing paradigms function as a means for nurse theorists and researchers to determine the congruence of their work in both focus and methods with the discipline of nursing, as expressed through a particular worldview.

Controversy The topic of nursing paradigms is much debated by nurse scholars with differing opinions articulated about which paradigm best serves the discipline's needs in regard to knowledge development. This debate has not always been viewed as particularly constructive. “The paradigm debates have done more to create divisiveness with theoretical nursing than to clearly define our unique mission and facilitate effective communication among nurses” (Thorne et al., 1998, A Unifying Definition, para. 1). The nursing literature reveals four major positions: (1) emergence of a singular dominant paradigm; (2) integration of the most predominant paradigms, that is, totality and simultaneity; (3) the coexistence of multiple paradigms; and (4) avoidance of the issue.

Kikuchi and Simmons (1996) arguing from the perspective of the logic of truth, which holds that “two contradictory positions cannot both be true —one must be true and the other false” (p. 8), seem to support the necessity of a single dominant paradigm for the discipline of nursing. It has been argued that a predominant paradigm demonstrates the legitimacy of the science of a discipline. When Parse (1987) labeled and described the

totality and simultaneity paradigms, she acknowledged the existence of a dominant paradigm and suggested the emergence of a new and preferred perspective for nursing. She identified the simultaneity paradigm as “an alternative to the traditional predominant worldview in nursing [totality],” one that moves “nursing away from the particulate view of Man” (p. 135). She noted that the simultaneity paradigm was gaining “recognition among scientists and was “beginning to have an impact on research and practice competitive with the totality paradigm” (p. 135). Her use of the term “competition” initiated a debate over a preferred paradigm for nursing that is ongoing. The case for a single dominant paradigm is articulated by Leddy (2000); citing Kim, she concluded that multiple paradigms, instead of leading to coherence and patterning, actually results in “chaos, fragmentation, and arbitrariness” (p. 229). Others support the existence of a single dominant paradigm, but one that has not yet been identified. “The dialog is not to determine which [existing] paradigm is, finally, to win out. Rather it is to take us to another level at which all of these paradigms will be replaced by yet another paradigm whose outlines we can see now but dimly, if at all” (Guba, 1990, p. 27). Some nurse scholars have suggested new paradigms. For instance, Georges (2003) recommends a paradigm that claims social justice as the central teleology of the discipline's scholarship, one that is critical of dominant practices, and embraces diversity and the contextual nature of phenomena.

A variation on the position that nursing is best served by a single paradigm is the recommendation made by some nurse scholars that a paradigm integrating both the totality and simultaneity paradigms become the dominant perspective of the discipline. Rawnsley believes that “constructing new paradigms to complement totality and simultaneity is one way of respecting the contributions of colleagues without compromising philosophical integrity” (Rawnsley, 2003, p. 11). Several nurse scholars have suggested this approach and Winters and Ballou (2004) identified integration as a trend that values not only the traditional scientific worldview but also the phenomenological and philosophical worldviews (p. 535).

Arguing for “a less extreme and more integrated reference point for nursing's theory and practice,” Thorne and her coauthors proposed a unifying definition of nursing (Thorne et al., 1998, p. 1257), with human health and illness processes as the core. Nursing practice is facilitating, supporting, and assisting individuals, families, communities, and/or societies to enhance, maintain, and recover health and to reduce and

ameliorate the effects of illness. Nursing's relational practice and science are directed toward the explicit outcome of health-related quality of life within the immediate and larger environmental contexts (Thorne et al., 1998, A Unifying Definition, p. 1265).

Engebretson (1997) proposed an integrative paradigm, derived from the Heterodox Explanatory Paradigms Model for health practice. This model consisted of a horizontal axis with a continuum from logical positivism to metaphysics and a vertical axis with mind–body dualistic types of healing. Rawnsley (2003) conceptualized two paradigms that she believed promoted an inclusive nursing science, the heuristic paradigm and the complementarity paradigm. The focus of the heuristic paradigm is a valuing of the process of discovery and of the complementarity paradigm a valuing of inclusiveness. Roy is also a proponent of an integrative paradigm, which she refers to as unity in diversity (Guiliano et al., 2005, p. 246). She believes in the existence of universal truths and that knowledge generated from multiple perspectives can and should be unified to serve the needs of nursing practice.

Willis, Grace, and Roy (2008) also proposed a unifying paradigm that focuses on facilitating humanization, meaning, choice, quality of life, and healing in living and dying. They based their paradigm on a 2-year inquiry process to identify a central focus for the discipline. They claimed a number of assumptions as a basis for their inquiry. Among the 11 proposed assumptions were that nursing requires a central unifying focus and that this focus will not change over time (p. E29).

Risjord (2010) has entered the discussion by proposing an integrative, unitary paradigm that acknowledges the significance of both science and values in nursing. He suggests “nursing standpoint” derived from the feminist philosophers' “standpoint epistemology” as the perspective that best represents the nature of nursing. From this perspective, nurses occupy subordinate roles and therefore can achieve a less distorted view of the world they occupy. He claims that (1) the role of nurses in health care is marginalized; (2) the relationship between nurses and physicians focuses on the needs of physicians; (3) nursing work is basically invisible; and (4) nurses are required to understand both the patient's and the physician's perspectives on the health of the patient. Within this paradigm, there is a commitment to develop the knowledge of the nurse who occupies this special social role and to value the patient's autonomy and well-being and the unique nursing role (pp. 71–72).

The third position in this debate is that nursing science is best served

by a multiparadigm perspective. As noted by Pilkington and Mitchell (2003), other disciplines exist with multiple and distinctively different paradigms (pp. 107–108) and Barrett (1992) claims uniformity of perspective is neither possible nor desirable (p. 156). Other nurse scholars express similar views. Whitehead (2005) claims “that the real reality is that there is not single reality or truth in nursing practice and subsequently no one method [for acquiring knowledge] prevails over the next.” Fawcett (2003) also acknowledges the contributions of both the totality and simultaneity paradigms (p. 273). Those who support the multiple paradigm perspective have concluded that the complexity of the knowledge base that nurses need to practice requires paradigmatic plurality. “The existence of multiple paradigms in nursing science indicates a strong and flourishing science….because they encourage creativity, stimulate debate and the exchange of ideas, provide diversity of views, promote productivity, and keep open avenues of inquiry” (Monti & Tingen, 1999, p. 75).

Though not as common as the other positions, some nurse scholars are suggesting that the paradigm debate be suspended. Thorne et al. (1998) claim that “paradigm discourse inhibits rather than fosters productive knowledge development within the discipline (p. 124),” certainly a serious indictment. They identify the dichotomies in perspectives (old versus new) that become the focus of discussions on paradigms as unhelpful in synergistic knowledge development. Kikuchi (2003) suggests a rejection of worldviews, that is, paradigms, in favor of a philosophy of moderate realism with its emphasis on probable, not absolute, truths and on a belief that reality exists independent of the human mind.

This approach to nursing knowledge development is viewed as a public enterprise, one in which (1) questions are posed that all scholars can answer; (2) questions are answered in a piecemeal fashion; (3) there is both agreement and disagreement regarding the answers proposed; (4) disagreements are resolved using a accepted standards; and (5) scholarly work is cooperative so that the cumulative knowledge can better answer the questions. This avoidance of the paradigm dilemma may be a trend. Cody and Mitchell (2002) noted that there were decreasing numbers of publications addressing the fundamental philosophical issues of nursing, that is, ontology and epistemology. By definition, paradigms cannot be discussed without consideration of questions of ontology and epistemology.

The paradigm debate remains unresolved. Without the emergence of a single dominant paradigm, nursing is left with multiple paradigms that are

either competing or complementary or with the need to develop an integrated paradigm that dialectically combines the perspectives of the multiple paradigms. With this state of paradigm confusion, it would be helpful for nurse theorists to identify the paradigmatic perspective from which the theory is developed and nurse researchers to identify the paradigmatic perspective from which the research questions were posed and the research methods chosen.

Conceptual Models Conceptual models are a “set of interrelated concepts that symbolically represent and convey a mental image of a phenomen[on]” (Fawcett & Alligood, 2005, p. 228). Adam (1992) claims that they are the cornerstone of nursing's development (p. 61). Conceptual models are considered less abstract and more explicit and specific than philosophies but more abstract and less explicit and specific than theories (Adam, 1992; Alligood & Tomey, 2005; Caper, 1986; Fawcett, 2005b). The term conceptual model has been used interchangeably, accompanied by some controversy, with conceptual framework, theoretical framework, conceptual system (King, 1997), philosophy (Adam, 1992), disciplinary matrix, paradigm, theory (Dickhoff & James, 1968; Fitzpatrick & Whall, 2005; Meleis, 1997), and macro theory (Adam, 1992).

Beginning in the 1960s, conceptual models emerged as nursing attempted to distinguish itself from other disciplines, especially medicine (Kikuchi, 1992; Schlotfeldt, 1992). Since the 1960s, nursing models have been developed, proposed, analyzed, critiqued, and refined. Table 1.4 provides examples of the work of nurse scientists during that time period that have been labeled as conceptual models.

Table 1.4 Conceptual Models

In recent nursing literature, the term conceptual model seems to focus on less global and more specific phenomenon, for instance, the integrative conceptual model on nurse turnover (Battistelli, Portoghese, Galletta, & Pohl, 2013) and conceptual model of quality of life for children with cancer (Anthony et al., 2014). These models seemed designed more to “… orient research and practice by guiding the selection of problems and making phenomena salient” (Risjord, 2010, p. 173).

Development Conceptual models are typically developed through the three stages of conceptualization: formulation, model formalization, and validation (Young, Taylor, & Renpenning, 2001, p. 11). The process can be empirical or intuitive, deductive or inductive. Empirically, nurse scholars make observations from practice; intuitively, they develop insights. Deductively, they combine ideas from a variety of areas of inquiry, particularly other theories (e.g., general systems) and scientific bases; and inductively, they generalize from specific situations or observations. Conceptual nursing models reflect assumptions, beliefs, and values and, according to Adam (1992), are composed of six units, with commonly occurring philosophical perspectives. The following list summarizes the units and philosophical

perspectives with examples from Johnson's Behavioral System Model.

1. Goal of nursing, generally idealistic, pragmatic, and humanistic; for instance, “fostering effective and efficient behavioral functioning” (Johnson, 1990, p. 24).

2. Conceptualizations of the client, usually existential and humanistic, and almost certainly holistic; as evidenced by Johnson's eight behavioral subsystems (Grubbs, 1974).

3. Social role of nurse, often humanistic and idealistic; for example, nursing is viewed as a service that makes a unique contribution to the health and well-being of individuals—specifically, nurses act to “provide a distinctive service to society” (Grubbs, 1974, p. 160) and “to seek the highest possible level of behavioral functioning [for the patient]” (Grubbs, 1974, p. 161).

4. Source of difficulty, primarily pragmatic, because it identifies the scope of nursing's responsibility; for instance, behavioral disequilibrium and unpredictability, indicating a malfunction in the behavioral system (Grubbs, 1974).

5. Intervention, typically humanistic, idealistic, and pragmatic; for example, restrict (e.g., set limits on dysfunctional behavior), defend (e.g., use isolation techniques), inhibit (e.g., teach new skills), and facilitate (e.g., provide adequate nutrition) (Grubbs, 1974).

6. Desired consequences, also typically humanistic, idealistic, and pragmatic; as evidenced by Johnson's goal of system balance and stability (Grubbs, 1974; Johnson, 1990).

Though Johnson's Behavioral System Model was used as one example of how these components are addressed in a conceptual model, all the conceptual models found in Table 1.4 consider these six components, each from its unique perspective.

Uses The development of conceptual models is essential to the professional identity of nursing. The conceptual models delineate the goals and scope of nursing and provide frameworks for considering the outcomes of nursing. In general, they can direct a professional discipline's theory development, practice, education, and research.

Conceptual models can give birth to nursing theories. Fawcett (2005b)

claims that “grand theories are derived directly from conceptual model” (p. 19). Because, by definition, conceptual models are considered more abstract and less specific than theories, several can develop from a single conceptual model. For instance, several grand theories were derived from Roger's conceptual model, the Science of Unitary Human Beings. The Theory of Power as Knowing Participation in Change (Barrett, 1986) is one example of a theory with its origins in Roger's conceptual model. The alternate view is that conceptual models are “not necessary, and, perhaps, not even important for theoretical growth” (Rodman, 1980, p. 436). Theories can be derived from other sources. For instance, Leininger's Theory of Cultural Care Diversity and Universality was derived from anthropological concepts, research, and her beliefs about nursing. Peplau's Theory of Interpersonal Relations was based on an integration of theories from the field of psychology and the recorded interactions between student nurses and patients.

The relationship between nursing's conceptual models and practice is a reciprocal one. Conceptual models can provide a structure for nursing practice and practice experiences can provide evidence of the credibility of the model (Kahn & Fawcett, 1995). In order for a conceptual model to be considered useful, it must demonstrate (1) social utility—content is understandable and the interpersonal and psychomotor skills needed to apply the model can be mastered; (2) social congruence—nursing activities are culturally congruent with the expectations of the patient, community, and members of the health care team; and (3) social significance—the use of the model provides outcomes of social value, particularly as it relates to patients' health status (Kahn & Fawcett, 1995, p. 189). In practice, the models have most often been used as a framework for implementation of the nursing process (Archibald, 2000, Nursing Models, para. 2).

Assessment based on a conceptual model tends to be more comprehensive, focused, and specific (Hardy, 1986). Historically, because of their level of abstraction, models tended to be less effective in prescribing specific nursing interventions. Instead, the conceptual models suggested general areas of nursing action. The unique focus of each conceptual model also implies criteria for determining when problems have been solved, thus aiding the process of evaluation.

Because recently developed conceptual models are more focused on a specific phenomenon, they could be used prescriptively in practice. For instance in their model, Benoit and Mion (2012) suggest risk factors for

the development of pressure ulcers in critically ill patients and Giovannetti et al. (2013) in their model identify performance measures for people with multiple chronic conditions.

Many schools of nursing used conceptual models as a framework for their curricula. The use of nursing's conceptual models ensured that the focus of the students' education was on nursing, not medicine. It provided students with a perspective for considering nursing issues and a language for expressing such. Beginning in the 1960s and through the 1990s, schools of nursing have identified the use of specific conceptual models in their curricula, for example, Johnson's Behavioral System Model (Harris, 1986), King's General Systems Framework (Brown & Lee, 1980), Neuman's Systems Model (Kilchenstein & Yakulis, 1984), Roy's Adaptation Model (RAM) (Brower & Baker, 1976), and Popoola Holistic Praxis Model (Popoola, 2012).

Conceptual models can also guide research. “Research is nursing research only if it examines phenomena of special interest to nursing, that is, phenomena that are indicated by one or the other of the conceptual models for nursing” (Adam, 1992, p. 59). Since conceptual models for nursing represent foci of scientific inquiry, they can identify questions for research. For instance, conceptual models generated the following questions: (1) In Johnson's Behavioral System Model, what are the effects of the stage of cancer on the eight behavioral subsystems? (Derdiarian, 1988); (2) In King's General Systems Framework, what factors interfere with goal attainment? (Kameoda & Sugimori, 1993); and (3) In Neuman's System Model, what effect did experience with the model have on the quality of nursing diagnoses? (Mackenzie & Spence Laschinger, 1995). It is important to note that avenues of questioning suggested by conceptual models are not the same as those of empirical testing, which less abstract theories undergo. The more recently developed conceptual models are generating specific hypotheses that are tested in research. For instance, research by Gobbens, Van Assen, Luijkx, and Schols (2012) tested the hypothesis that the effects of disease are mediated by frailty. This hypothesis was derived from the integral model of frailty.

Controversy There are some controversies about the use and usefulness of conceptual models. Although conceptual models from the 1960s through 1980s were

criticized as being too abstract to be tested or validated (Adam, 1992; Downs, 1982), they can and should be evaluated. Evaluation of conceptual models has revealed some general limitations. They have been criticized for:

Their level of abstraction, limiting their usefulness Rigidity and inflexibility, which inhibit change The subjectivity of perspective, which may not be shared by professional colleagues or clients The use of a unique language or jargon, requiring specialized education or resulting in confusing communication Potential to be used in inappropriate situations and for incorrect purposes (Adam, 1992; Hardy, 1986; Littlejohn, 2002; Tierney, 1998; Young et al., 2001)

Controversy about the use of conceptual models in relation to theory development is complicated by lack of consistency in labeling the work of nurse scientists. Fawcett's (2005b) position is that conceptual models are more abstract and global and less specific than theories. Kramer (1997) identifies conceptual models as a type of theory but claims not all theories are conceptual models. Meleis (1997) concludes that most of the differences between the two are semantic and noted that the nurse scientists themselves referred to their work using a variety of terms. For instance, Rogers called her conceptualization of nursing a science (Science of Unitary Human Beings); Erickson referred to her work as both a theory and a paradigm (Modeling and Role Modeling: A Theory and Paradigm); and Watson identified her thinking as both philosophy and theory (Watson's Philosophy and Theory of Human Caring). Although there is some confusion about the term and some limitations regarding their use, conceptual models have proved valuable for the advancement of nursing research and the development of theories.

Theory: General Issues Similar to conceptual models, theories are composed of concepts and propositions. In a theory, the concepts are traditionally defined more specifically and the propositions are more narrowly focused. Though theory and paradigm are sometime used interchangeably, theories differ

from both paradigms and philosophies in that they represent what is rather than what should be (Babbie, 1995, pp. 37, 47). A theoretical body of knowledge is considered an essential characteristic of all professions (Johnson, 1974). Therefore, theories serve to further specify the uniqueness or distinctiveness of a profession. “Theories have in fact distinguished nursing from other caring professions by fixing professional boundaries” (Rutty, 1998, Theory, para. 2). The definition of theory by Kerlinger is classic and comprehensive. “Kerlinger (1973) defines theory as follows: A theory is a set of interrelated constructs (concepts, definitions, and propositions) that present a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting phenomena” (King, 1978, p. 11). In addition to explanation and prediction of phenomena, Glaser and Straus (1967) identify other uses of theory. They believe theories by definition should also be able to further advance theory development; guide practice by providing understanding and the possibility of controlling some situations; offer a perspective on behavior, a means of interpreting data; and provide an approach or style for the research of a specific area of human behavior. Theories should be inherently useful.

In addition to considering the development and uses of nursing theories, it is important to address their classifications. Theories can be classified in a number of ways: by their purposes, sources, and levels. The three major levels of nursing are grand, middle range, and practice, with middle range theory of special interest as it grows in importance in nursing research and practice. As with philosophies, metaparadigms, paradigms, and conceptual models, there are a number of controversies surrounding nursing theories.

Development The development of a theory involves both content and process. Theories are composed of concepts and their relationships and are constructed through a variety of processes. The history of theory development in nursing helps provide a context for understanding the ongoing work of nurse scientists in the advancement of nursing's body of knowledge.

Components

A variety of terms are used to describe concepts and propositions, the two basic elements of a theory. The terms concept, construct, descriptor, and unit are often used interchangeably, with concept being the most common. Definitions of the concepts can be considered an aspect of the basic element, concept, or as a separate and additional component of a theory. Statements of relationships or propositions refer to the same notion. Also, some scientists include axioms and postulates as other components of a theory. Though they are relational statements, axioms or postulates are considered unique in that they are the assertions assumed to be true that lay the groundwork for the propositions (Babbie, 1995, p. 48).

Concepts. Concepts are considered the basic building blocks of theory. Kim (2000, p. 15) defines concepts as “a symbolic statement describing a phenomenon or a class of phenomena.” In other words, a concept is a mental representation of a phenomenon, an idea or construct of an object or action (Walker & Avant, 2011, p. 59). Although there are several more complicated classifications of concepts (or units), basically they can be classified on a continuum of abstractness, which some label primitive, abstract, and concrete (Meleis, 1997) and others global, middle range, and empirical (Moody, 1990). They can also be categorized as property or process concepts (Kim, 2000).

Primitive concepts are those that have a culturally shared meaning (Walker & Avant, 2011, p. 59) or are those that are introduced as new in the theory (Meleis, 1997, p. 252). For instance, in culturally derived concepts, a color is usually primitive because it cannot be defined except by giving examples of another color different from the original color. Grass and apples would be examples of green and sky, and coal would be examples of not green. As an original concept in a new theory, role supplementation in the theory of “Role Insufficiency and Role Supplementation” would be an example of a theory-specific primitive concept (Meleis, 1997, p. 252).

Concrete concepts are those that exist in a spatial–temporal reality. They can be defined in terms of primitive concepts. Grass, leaves, apples, sky, and coal would all be examples of concrete concepts. In nursing, touch used by the nurse would be considered a concrete concept. Abstract concepts can be defined by primitive or concrete concepts but are not limited by time or space. “They refer to general cases” (Kim, 2005, p. 16).

Communication could be identified as an abstract concept that would be of interest to nursing. Theories can include both concrete and abstract concepts.

For theories using abstract concepts, operational definitions of those concepts are an important inclusion because the definitions enable the theory to be more easily tested empirically through research. An operational definition “assigns[s] explicit meaning to that [abstract] concept” (Duldt & Giffin, 1985, p. 95). Operational definitions can be (1) experimental, providing specific details necessary to manipulate the concept; (2) measurable, describing the means by which the concept can be measured; (3) administrative, including particular information on how to obtain data about the concept; and (4) evaluative, establishing the criteria for operationalizing the concept and the means of determining the degree to which the criteria are met.

The classification of concepts as property or process is significant because it promotes understanding of the concept as defined by the theorist. Property concepts are those that deal with the state of things and process concepts are those that relate to the way things happen. Stage of grief would be a property concept, whereas grieving as the means by which an individual deals with loss would be a process concept. A concept can be considered both a property and process concept, such as communication. In general, theories contain both types of concepts. “The classification system of concepts into property and process types is useful in an analytic sense” (Kim, 2000, p. 18). It provides a clearer sense of the nature of the concepts included in the theory and thus a better understanding of the theory itself.

Propositions. Propositions, defined as statements of the relationships between two or more concepts, provide a theory “with the powers of description, explanation or prediction” (Meleis, 1997, p. 252). Propositional statements can be considered either relational or nonrelational. Relational statements can be either correlational or causal. Nonrelational statements include descriptions of the properties and dimensions of the concept in the definition of the term proposition (Meleis, 1997).

In propositional statements that are correlational, the assertion is that two or more concepts exist together or are associated. The associations can be positive, negative, or neutral. Orem's Self-Care Deficit Nursing Theory

provides examples of positive and neutral correlational statements. The nurse affects the movement from the “‘present state of affairs' to ‘a desirable future state of affairs' by using the ‘nursing means' the nurse selects” (Orem, 2001, p. 151) is an example of a positive correlational statement. “Engagement in self-care or dependent-care is affected by persons' valuation of self care measures with respect to life, development, heath, and well-being” (Orem, 2001, p. 146) is an example of a more neutral or directionless correlational statement.

Causal propositional statements establish cause-and-effect relationships. Examples of causal statements are found in Parse's Man- Living-Health Theory of Nursing. “In a nurse–family process, by synchronizing rhythms, the members uncover the opportunities and limitations created by the decisions made in choosing irreplaceable ways of being together. The choices of new ways of being together mobilize transcendence” (Parse, 1987, p. 170). Causal statements are more difficult to establish than are correlational statements and therefore more rare.

“Nonrelational statements provide assertions of the existence of concepts or definitions of concepts of a theory and thus help explain the nature of the theory. An example of a nonrelational existence proposition would be Parse's statement that the practice methodology of her theory is composed of three dimensions: illuminating meaning, synchronizing rhythms, and mobilizing transcendence (Parse, 1987, p. 167). Parse also provides nonrelational definitional propositions, for example, “health is Man's unfolding. It is Man's lived experiences, a non linear entity that cannot be qualified by terms as good, bad, more, or less” (Parse, 1987, p. 160).

The nature of the elements of the theory relates to the purposes for which the theory can be used. Theories with only nonrelational propositional statements serve to describe, whereas theories with relational propositional statements have the potential to explain (correlational statements) and predict (causal statements).

Process Walker and Avant (2011) describe strategies of theory development that involve analysis, synthesis, and derivation, which can be applied to concepts, statements, and/or theories. Analysis involves examination of the structural and functional components of a concept, relational statement,

and/or theory. This process provides a means to clarify, refine, and hone existing theoretical knowledge (p. 64). Synthesis is used to combine pieces of information, often observations from research, for the purpose of identifying or defining a new concept, relational statement, or theory (p. 63). Derivation involves transposing and modifying a concept, relational statement, or theory from one discipline to another, providing a more meaningful context for nursing (p. 63). Walker and Avant (2011) describe in detail these processes in their book, Strategies for Theory Construction in Nursing.

Lenz, Suppe, Gift, Pugh, and Milligan (1995) used these processes as they collaborated on the development of the middle range theory of unpleasant symptoms. For instance, the researchers used existing literature for concept analysis, examining attributes, characteristics, and dimensions of the concept of dyspnea. The literature review also served as a basis of concept derivation, resulting in the identification of pain as an analog of dyspnea. And through synthesis of the literature and the researchers' own experiences, they conceptualized dyspnea as having five components: sensation, perception, distress, response, and reporting.

Sources The content of a theory comes from other theories, practice, or research or a combination of two or more of these sources. Theories from other disciplines are one source of nursing theory content. Informed by their clinical practices, psychiatric and pediatric nursing, respectively, Peplau made use of psychoanalytic theory and Johnson made use of systems theory. Nursing theories and conceptual models often give rise to middle range theory. For instance, from Orem's Self-Care Deficit Theory came the Theory of Dependent-Care Deficit, Theory of Self-Care, and Theory of Nursing Systems (Alligood & Tomey, 2005, p. 53).

“Some theories are driven by clinical practice situations and are inductively developed” (Meleis, 1997, p. 230). This grounded theory approach uses observations and analysis of similarities and differences of observed phenomena to develop concepts and establish their relationships. The works of Peplau, Orlando, Travelbee, and Wiedenbach have been associated with this approach.

Research is often cited as the most common and acceptable source for theory development, frequently leading to the development of a middle

range theory. “Theories evolve from replicated and confirmed research findings” (Meleis, 1997, p. 231). This is considered an empirical quantitative approach and involves (1) identifying a phenomenon, listing all its characteristics; (2) measuring these characteristics in a variety of settings; (3) analyzing the results to determine if patterns exist; and (4) formalizing these patterns as theoretical statements (Reynolds, 1971, p. 140). Johnson and Rice's (1974) theory of sensory and distress components of pain was developed using this approach.

Qualitative research is often referred to as theory generating, with grounded theory and phenomenology often used by nurse scientists to develop theories. Fagerhaugh's (1974) theory of pain expression and control is an example of theory developed through qualitative research. Metasynthesis is emerging as an approach for developing theory, especially middle range theory (Annells, 2005; Walsh & Downe, 2005). This method addresses the criticism that theory development from qualitative research relies on a small number of homogeneous participants (Estabrooks, Field, & Morse, 1994). Metasynthesis involves aggregation of qualitative data, employing four processes—“comprehending, synthesizing, theorizing, and recontextualizing” (Estabrooks et al., 1994, p. 505)—with greatest emphasis on theorizing and recontextualizing. Dynamics of hope in adults living with HIV/AIDS: a substantive theory was developed using metasynthesis (Kylma, 2005). McKenna (1997) noted similarities between the quantitative and qualitative approaches: both use inductive methods, and both generally result in the development of middle range theories.

History Nursing theory development can trace its roots to the work of Florence Nightingale (Alligood & Tomey, 2005; Dunphy, 2001; Fitzpatrick & Whall, 2005; Meleis, 1997), with her concern for the relationship between health and environment and the nurse's role in that relationship. Hildegard Peplau is credited with being the first contemporary nurse theorist (McKenna, 1997). Other theorists of the 1950s (Henderson [in Henderson and Harmer], 1955; Orem, 1959; Johnson, 1959; Hall, 1959) (McKenna, 1997, p. 95) were influenced by Peplau's conceptualization of interpersonal relationships in nursing. Others were influenced by their involvement at Columbia University's Teachers' College and the practical- oriented philosophy of John Dewey, who served on its staff. From

Teachers' College in the 1950s, Abdellah, King, Wiedenbach, and Rogers emerged as nurse theorists (Meleis, 1997). Not all of the work of these nurse scientists would be considered theory by today's definition. The theoretical work that did take place in the 1950s focused on what nurses did, not why or how they did it, and the conceptual frameworks developed at this time were more often used as a basis for the development of curricula than as a guide for practice. The 1950s also saw the introduction of the journal Nursing Research, which provided a forum for the development of nursing theories and their testing.

In addition to continuing development of individual nursing theories, the 1960s brought a more national and coordinated approach to theory development. Federal financial support became available in 1962 to nurses pursuing doctoral education; the American Nurses Association stated in 1965 that theory development was a significant goal for the profession; and in 1967, Case Western Reserve University sponsored a national nursing symposium, a third of which was devoted to nursing theory. The theorists associated with this decade include “Abdellah et al. (1960), Orlando (1961), Wiedenbach (1964), Levine (1966), Travelbee (1966) and King (1968)” (McKenna, 1997, pp. 95–96). Theorists, particularly Wiedenbach and Orlando, began to consider not only what nurses did but what effect it had on patients. Debate, stimulated by the metatheorists, focused on the issue of the types of theories that nursing should develop rather than the content of theories.

Although nursing theorists continued to develop and publish their work, Rogers (1970), Neuman (1972), Riehl (1974), Adam (1975), Patterson and Zderad (1976), Leininger (1978), Watson (1979) and Newman (1979) (McKenna, 1997, p. 97), and Roy (2014), the questions posed by metatheorists dominated the decade of the 1970s (Meleis, 1997). Efforts were made to determine what is meant by theory, to identify the structural components of theories, and to clarify the methods of analysis and critique of theory. The previously developed theories were criticized for a failure to include explicated propositions and for their lack of empirical testing (McKenna, 1997, p. 97). The development and use of nursing theories were advanced by (1) the adoption by the National League for Nursing of an accreditation criterion requiring a theory base to nursing curricula, (2) the formation of two groups (Nursing Theories Conference Group and Nursing Theory Think Tank) that considered application of theory to practice, and (3) the publication of Advances in Nursing Science, a journal dedicated to the development of nursing

science. Alligood and Tomey (2005) refer to the 1980s as the Theory Era, even

though few new nursing theories emerged. “Only three new nursing theories were published in the 1980s: the work of Parse (1981); Fitzpatrick (1982); and Erickson, Tomlin, and Swain (1983) (McKenna, 1997, p. 97). Fawcett's (1984, 1989) explication of a metaparadigm for nursing allowed for the comparative content analysis of theories, and her delineation of the levels of abstraction of nursing knowledge helped nurse scientists and practitioners make the distinctions between grand, middle range, and practice theories. Her work also clarified how nursing grand theory can be derived from nursing conceptual models and how middle range theory can be derived from grand theory. The importance of nursing theory to the profession was well established and the shift by the end of this decade was away from theory development toward theory use (Alligood & Tomey, 2005, p. 9). There was both an increased interest in the relationship between theory and practice and an increased emphasis on the relationship between theory and research.

The decade of the 1990s was hallmarked by the development of the middle range and practice theories. These theories are less abstract and therefore more directly applicable to practice and more easily tested empirically by research. Interest in nursing theory was evidenced by the publication of Nursing Science Quarterly, edited by Parse, focusing on theory development and testing and by the increasing number of European-based nursing theory conferences.

Six trends emerged during the decade of 2001–2011 (Im & Chang, 2012). From three data bases, using search criteria to identify articles that included content on nursing theory, Im and Chang reviewed 17, 549 abstracts and identified 2,317 relevant articles. From the analysis of these articles, they identified the following trends: (1) specific focuses—theory work was more about the specific concepts of existing theories, rather than the development of new ones; (2) coexistence of theories—all levels of abstraction and various methods of theory development were included; (3) linkage of theory to research—research was used for theory development and theories served as frameworks of research studies; (4) international collaboration—theories developed by American theorists were applied to international settings and publications often had American coauthors; (5) application to practice—there was an emphasis on development of prescriptive theories to guide practice; and (6) selective evolution—further development or refinement of theories primarily focused on only four

grand theories, that is, Roy's adaptation, Orem's self-care, Neuman's systems, and Roger's unitary human beings. These trends suggest an encouraging future for theory development and theory use in research and practice.

Uses Nurse scientists have worked on the development of nursing theory as part of the process of establishing nursing as a profession with a unique body of knowledge. Nursing theories provide nurses with the language of nursing, a means of communicating the nature of the discipline within and outside the profession. In addition, as a component of nursing knowledge considered less abstract than conceptual frameworks, nursing theories generate more specific research questions and provide greater guidance to nursing practice.

Nursing theories provide nursing-specific identifications, definitions, and interrelationships of concepts. This allows the profession to distinguish itself from the medical and behavioral sciences. For example, in nursing, we speak of unitary human beings, self-care, and the centrality of caring. Through analysis of theories, nursing's metaparadigm emerges, providing us with a common and basic frame of reference for communicating about nursing.

The relationship between nursing theory and research is symbiotic. Research provides for both theory generating and theory testing. Qualitative research seeks to identify and define phenomena of interest to nursing, thus serving as a theory-generating tool. By contrast, quantitative research is a means by which the propositions of theories can be substantiated, thus functioning as a theory-testing tool. Theories then serve as a framework for relating the data generated by research, resulting in a more coherent whole nursing body of knowledge than a collection of isolated facts.

In addition, the greater clarification of concepts and their relationships that nursing theories provide allows researchers to formulate more specific and nursing-relevant research questions. The evidence that is generated through the study of these questions, because of the level of specificity and relevance, in turn is more directly applicable to nursing practice. Parse (1999) challenges nurses “to conduct research to ensure that the practice of nursing serves people in a unique way” (Recommendations, para. 1). It is

through nursing theories that the profession identifies its unique service to people. The testing of nursing theories also leads to theory-guided evidence-based practice. “Evidence itself refers to evidence about theories. Similarly, theory determines what counts as evidence” (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001). Thus, theory as it guides research has the potential to provide the evidence that makes nursing practice more efficient and more effective.

Classifications Theories differ in their purposes, sources, and, most importantly, levels of abstraction and scope. These differences lead to classifications. The basic purposes of theory are description, explanation, prediction, and/or control. The sources of theory in nursing include those developed by nurse scientists (unique) and those that are used in nursing but come from other disciplines (borrowed). The terms “theory of nursing” and “theory in nursing” are often used to distinguish between these two sources, respectively.

Abstraction and Scope There are multiple terms used to classify the various levels or scope of nursing theories. The broad-scope theories are referred to as “macro,” “holistic,” “molar,” “general,” “situation,” and, most commonly, “grand.” Narrow-scope theories are called “middle range,” “circumscribed,” or “situation/factor.” Theories narrowest in scope are labeled “micro,” “molecular,” “atomistic,” “narrow range,” “phenomena,” “prescriptive,” “factor,” “situation-specific,” or “practice” (Babbie, 1995; George, 1995; Parker, 2006; Rinehart, 1978). The most common labels for the levels of nursing theory are grand, middle range, and micro, practice, or most recently situation-specific. The level is determined primarily by the theory's degree of abstraction. Examination of the level of abstraction of the “purpose, concept, and definitional components of the theory” (Kramer, 1997, p. 65) allows for the identification of the level of the theory.

Purposes

Though theories are designed to describe, explain, predict, and/or control, some nurse scientists claim that only theories that enable nurses to control outcomes are legitimate for a practice discipline (Dickhoff & James, 1968). Descriptive theories are limited to naming and classifying characteristics of the phenomenon of interest, which identify what is happening. Peplau's Theory of Interpersonal Relationships has been labeled a descriptive theory.

Explanatory theories expand the knowledge base by delineating the relationships between characteristics of the phenomenon, clarifying why it is happening. Watson's Theory of Human Caring is considered an explanatory theory. But predictive theories provide the conditions that can result in a preferred outcome, determining how it can intentionally happen. Orlando's Theory of the Deliberative Nursing Process is an example of a predictive theory. Theories whose purpose is to control, often referred to as prescriptive theories, guide action to create an intended result. The three ingredients for this type of theory are content of goal, primary prescription for activity to achieve goal, and list of additional recommendations of activity (Dickhoff & James, 1968, p. 201).

The existence of descriptive and explanatory theories is a necessary precursor to the development of predictive and prescriptive theories. “Predictive theory presupposes the prior existence of more elementary types of theories” (Dickhoff & James, 1968, p. 200). The relationship between the purposes of a theory has been conceptualized in some instances as a hierarchy:

1. Factor-isolating theories (descriptive) 2. Factor-relating theories (descriptive/explanatory) 3. Situation-relating theories (explanatory/predictive) 4. Situation-producing theories (prescriptive) (Dickhoff & James, 1968,

pp. 200–201)

Sources The source of theory refers to the discipline from which it developed. The possibilities include theories unique to nursing, theories borrowed from other disciplines, and theories from other disciplines adapted for nursing. A borrowed theory is one in which the knowledge “is developed in the main by other disciplines and is drawn upon by nursing” (Johnson, 1986, p. 118). The distinctions between these three sources is difficult to make

since “the man-made, more-or less arbitrary divisions between the sciences are neither firm nor constant” (Johnson, 1986, p. 117).

Given that the differences between the sources of theory may be less than perfectly precise, unique theory can be defined “as that knowledge derived from the observation of phenomena and the asking of questions unlike those which characterized other disciplines” (Johnson, 1986, p. 118). Many argue that nursing's identity as a profession and, ultimately, its ability to improve nursing practice are dependent on the existence of nursing theories unique to the discipline. According to Cody (1999), borrowed theories “do not contribute to the distinct core knowledge of nursing science, nor can practice guided by these theories be distinguished as uniquely nursing practice” (p. 12). Wald and Leonard (1964), who are also proponents of this position, claimed that to become an independent discipline, nursing is required to develop its own theories rather than borrow theories or apply principles from other disciplines. They expressed concern about nursing's reliance on these borrowed theories.

As recently as 2001, the literature reveals an ongoing reliance on theories from fields other than nursing. Fawcett and Bourbonniere (2001) found that of 90 research studies published in two clinical journals, Geriatric Nursing and Nurse Practitioner, and two research journals, Nursing Research and Research in Nursing and Health, only nine (10%) used nursing conceptual models or theories (p. 314). The borrowed theories or models used in these studies came from psychology, sociology, medicine, dentistry, physiology, biology, education, decision sciences, economics, ethics, epidemiology, management sciences, marketing, and communications.

Borrowed theories continue to be used with some frequency as the theoretical foundation of nursing research. Of the 47 research articles published in Nursing Research in 2006, only four (8.5%) used existing nursing theories, all in the middle range. The Theory of Unpleasant Symptoms was the only nursing theory tested in more than one study. Borrowed middle range theories were cited in 17 studies (36.2%), with social support, health-related quality of life, and self-efficacy the most commonly identified theories. There were no theories identified in 15 (31.9%) of the studies, and in 11 (23.4%) studies, models were created specifically for the research study from a variety of conceptual models and theories.

A survey of 47 studies published by Nursing Research in 2013 revealed fewer than 32% with any specifically identified theory or model.

None of the grand theory nursing theories was cited. The trend seemed to be use of a conceptual model, some which were adapted from a model or theory from another discipline, for instance, the Disablement Process from social science (Torma, Houck, Wagnild, Messecar, & Jones, 2013), and others created specifically for the study, for instance, the Theoretical Model of Heart Failure Self-Care (Dickson, Buck, & Riegel, 2013).

In past decades, the practice of borrowing theories seemed to be the result of a belief in the superiority of theories “imported” from other disciplines (Meleis, 1997). This perspective was reinforced by nurses whose advanced degrees were in fields other than nursing. Theories from sociology, psychology, education, ecology, physiology, and others were and still are borrowed. The argument for borrowed theories seems to be that theorists and practitioners should not place boundaries on any knowledge that might be useful to nursing because “knowledge does not innately ‘belong' to any field of science” (Johnson, 1986, p. 117). “… borrowing theories presents no threat to the discipline of nursing. A theory is appropriately used by nurse scholars insofar as it helps solve nursing problems” (Risjord, 2010, p. 39) and identifies an appropriate linkage between nursing and the other discipline.

Borrowing theories from other disciplines is sometimes referred to as theory adoption and involves the unchanged use of a theory developed from a field other than nursing. The use of unmodified theories from physiology, for instance, acid–base balance, is an example of a completely borrowed theory. Though the need for adopted borrowed theories does exist, there is concern about their prevalence. The preferred approach for the use of borrowed theories seems to be to adapt them to a distinctively nursing perspective.

As noted previously, nurses adapt borrowed theories. Adaptation refers to altering the content or structure of a theory that was initially developed for application to a discipline other than nursing. Borrowing and altering theory is seen as necessary “to acquire a means of explanation and prediction about some phenomena that is currently poorly understood, or for which there is no present means to study it, or for which there is no theory at all” (Walker & Avant, 1995, p. 172). The debate about the value of borrowed theories continues. Fawcett and Bourbonniere (2001) identify premises necessary for a healthy future for the nursing profession. They claim that “the discipline of nursing can survive only if we celebrate our own heritage and utilize nursing knowledge” (p. 311). This premise and the future it suggests are challenged by the ongoing dependence of nurses

on perspectives of nursing that are grounded in the knowledge of other disciplines. The solution they suggest is to end nursing's “romance” with borrowed theories. Few would argue that nursing needs to attend to the ongoing development of its unique body of knowledge, perhaps not for the sole purpose of divorcing itself from other disciplines but for creating a body of knowledge that could be shared across disciplines. Thus, nursing theory could be borrowed.

Controversy There are recurring themes in the criticisms of nursing theories: the issue of consistency in labeling, the appropriateness of the sources of the theories used by nurses, the creation of a theoretical hierarchy, and the often cited theory–practice gap. The lack of definitional clarity between what is labeled a conceptual model and what is considered a theory is further complicated by confusion over identification of the level of the theory, that is, grand, middle range, or practice/situation-specific. Nurse scientists have not consistently classified the level of the developed theory in the work they publish. This issue is further addressed in the discussion of the middle range level of theory development. In addition, there is some disagreement over the appropriate source of theories to be used by nurses, borrowed or unique. As noted in the section on classification of theories by source, the debate focuses onto what degree nurses can use theories from other disciplines and still advance nursing's unique body of knowledge. Risjord (2010) is the primary critic of the notion of a hierarchy of levels of nursing knowledge. He claims that

…the idea that theory must fit within a hierarchy of levels distorts the way in which theories work together to provide scientific understanding. Much scientific progress has been achieved when theories from different domains are integrated. (p. 116)

The response to that criticism is that different levels of abstraction can exist within a discipline without assuming a particular process of development. What is considered the most significant issue is a perceived and persistent “schism between efforts to create a discipline [the work of nurse theorists] …and the pragmatics of work and workforce” (Litchfield & Jónsdóttir, 2008, p. 81). The debate is whether nursing's theories are relevant or irrelevant to practice (Risjord).

Grand Theory Grand theories, as the most abstract of the three identified levels, attempt “to create a view of the whole of nursing” (Liehr & Smith, 1999, Juxtaposition with Grand Nursing theory, para. 1). They address the nature, mission, and goals of nursing care (Meleis, 1997) in a general fashion and are created through the observations and/or insights of the theorist. The development of grand theories served to differentiate the discipline of nursing from the medical model, stimulated the expansion of nursing knowledge (McKenna, 1997), and provided a general “structure for the organization of nursing knowledge” (Orem, 2001, p. 139). Orem also claimed that the unstructured nature of grand or general theories allows for a wide range of knowledge available to practitioners and scholars within a nursing-specific frame of reference. McKenna (1997) outlined the benefits of grand theories to include (1) a guide for practice as an alternative to practicing solely by tradition or intuition, (2) a framework for education by suggesting a focus and a structure for curricula, and (3) an aid to the professionalization of nursing by providing a basis of practice.

More than 50 grand theories have been identified (McKenna, 1997, p. 93), although that number may vary based on the label assigned to the work. Because of their level of abstraction, there has been some difficulty in distinguishing between grand theories, philosophies, and conceptual models. Examples of nursing theories that have been designated as grand include Leininger's Theory of Culture Care Diversity and Universality, Newman's Theory of Health as Expanding Consciousness, and Parse's Theory of Human Becoming (Fawcett, 2005b; Fawcett & Bourbonniere, 2001; Parker, 2006). Parker (2006) also identifies Orem's Self-Care Deficit, Roger's Science of Human Beings, and RAM as theories, whereas Fawcett (2005b) and Alligood and Tomey (2005) label these nursing scientists' work as conceptual models. xOrem (2001) refers to her work as a general theory. Table 1.5 provides sources of information about specific grand theories.

Table 1.5 Examples of Grand Theories with Sources of Information

The level of abstraction makes it difficult to test grand theories empirically. In fact, Donnelly (2001), citing the work of Lundh, Soder, and Waerness (1988), claimed that because the theories were abstract and normative “rather than facilitating research development [they] actually made research development in nursing ‘more difficult'” (p. 337). This conclusion is supported in part by the findings of Moody et al. (1988) that in nursing practice research published from 1977 to 1986, fewer than 13% of the 720 studies identified were linked to one of the grand theories.

Grand theories seem better able to serve as a basis for the development of the more specific theories of the middle and practice/situation-specific range, which can undergo empirical testing. For instance, the middle range theory, “A Theory of Sentient Evolution,” was derived from Roger's Science of Unitary Human Beings (Parker, 1989). In addition, grand theories have fulfilled the important functions of distinguishing nursing from other helping professions and providing legitimization to its science. But because of their success in fulfilling these functions, grand theories have become less necessary and the focus of theory development has changed to the middle range theories (Suppe, 1996a).

Middle Range Theory Compared to grand theories, middle range theories are less abstract.

Merton (1968), whose work served to promote the development of middle range theories, described them as lying between “the minor but necessary working hypotheses that evolve in abundance during day to day research and the all-inclusive systematic efforts to develop a unified theory....” (p. 39). Consistent with Merton's conceptualization, nurse authors have described middle range theories in comparison to grand theories as:

Narrower in scope (Fawcett, 2005b; Liehr & Smith, 1999; McKenna, 1997; Meleis, 1997; Parker, 2006; Walker & Avant, 1995) Concerned with less abstract, more specific phenomena (Fawcett, 2005b; Meleis, 1997) Composed of fewer concepts and propositions (Fawcett, 2005b; McKenna, 1997; Walker & Avant, 1995) Representative of a limited or partial view of nursing reality (Jacox, 1974; Liehr & Smith, 1999; Young et al., 2001) More appropriate for empirical testing (Liehr & Smith, 1999; McKenna, 1997; Meleis, 1997; Parker, 2006; Walker & Avant, 1995) More applicable directly to practice for explanation and implementation (McKenna, 1997; Walker & Avant, 1995; Young et al., 2001)

The attributes of middle range theories make them attractive to nurses who wish to engage in theory-based research and practice.

The appeal of these theories to nurse researchers and practitioners is demonstrated by their proliferation. In the 1980s, theory development in the middle range became of greater interest to nurse scientists with proliferation of these theories in the subsequent years (Lenz, 1996). Table 1.6 provides a partial listing of theories used by nurses in research and/or practice that have been considered to be middle range. Included in the table are middle range theories in various stages of development and testing classified by their primary focus. Most theorists identify their theory by a patient problem (e.g., acute pain and chronic stress), but some identify by the action or characteristic of the nurse (e.g., empathy and humor) or the desired outcome of an action (e.g., hope and maternal role attainment).

Table 1.6 Examples of Middle Range Theories

Development of Middle Range Theory Liehr and Smith (1999) outlined the relationships between the intellectual processes and the sources of content related to the development of middle range theories, which included:

Inductive theory, building theory through research Deductive theory, building from grand nursing theories Combining existing nursing and nonnursing theories Synthesizing theories from published research findings Developing theories from clinical practice guidelines (Approaches for Generating Middle Range Theory, para. 1)

Qualitative research, particularly phenomenological and grounded theory studies, has served as a source of middle range theory development. Ten qualitative studies conducted through the Nursing Consortium for Research on Chronic Sorrow provided a foundation for the development of the middle range theory of chronic sorrow (Eakes, Burke, & Hainsworth, 1998). The research findings of these and of other studies underwent concept analysis as part of the process of developing this theory. A major

source of middle range theory development is the qualitative research produced by nursing's PhD students and presented in their doctoral dissertations.

Several conceptual models and grand theories have served as the foundation for the development of middle range theories. Seiloff and Frey's (2007) book, Middle Range Theory Development Using King's Conceptual System, describes King's conceptual system and theory of goal attainment as a source for middle range theory development. A number of other grand theories have provided a foundation for further theory development.

One of the more ambitious projects involved the use of RAM (Roy, 2014). The Roy Adaptation Association Executive Board developed what they described as an alternative process for developing middle range theories for practice, one that involved analysis of 126 quantitative studies and 40 qualitative studies, which were organized around major propositional statements of the RAM. From this analysis and synthesis of the grouped studies, there emerged five middle range theories: (1) coping; (2) adapting to life events; (3) adapting to loss; (4) adapting to chronic health conditions, a lifelong process and common journey; and (5) the adapting to family. This approach provides a way of avoiding the proliferation of middle range theories lacking in coherence. It makes use of a grand theory and the body of research related to the theory as a means of developing middle range theories with clear application to practice.

Other examples of middle range theories derived directly and specifically from nursing's major conceptual models and grand theories are found in Table 1.7. For example, middle range theories have been developed from Johnson's Behavioral System Model, Levine's Conservation Principles, Roger's Science of Unitary Beings, and RAM (Alligood & Tomey, 2005).

Table 1.7 Middle Range Theories Derived From Conceptual Models

Theories from nursing have been combined with those from other disciplines to create middle range theories. Mercer used Rubin's work on maternal role attainment (i.e., attachment and role identity during pregnancy and early infancy) and integrated role and developmental theories from the field of psychology to arrive at her Theory of Maternal Role Attainment. She also conducted a number of research studies on the subject, the findings of which were reflected in the theory.

Published research findings have been cited as the most common source for constructing middle range theories of nursing (Lenz, 1998). The development of Online Social Support Theory is an example of this approach (LaCoursiere, 2001). Synthesized research findings from various patient populations (e.g., patients diagnosed with cancer or cardiovascular illness) that reflected the perspectives of those involved with the use of online social support (i.e., patient, caregiver, and nurse) served as a foundation for LaCoursiere's theory.

Clinical practice and clinical practice guidelines are sources of middle range theory development. Peplau is credited with introducing the use of clinical data in the development of her theory, the Theory of Interpersonal Relations. She based her understanding of the stages of the nurse–patient

relationship on the observations of interactions between student nurses and psychiatric patients. The guidelines established by the Agency for Health Care Policy and Research for the management of acute pain were used by Good and Moore in the development of the theory of a balance between analgesia and side effects in the management of pain.

It is important to note that most of the nurses involved in the development of middle range theories used more than one approach. As part of arriving at the creation of the middle range theory, often findings from previous research studies were reviewed and analyzed, conceptual models and theories were considered, and additional research was conducted that targeted the phenomenon of most interest.

Uses of Middle Range Theory Middle range theory has been found to be useful in both research and practice. “Theory can serve a heuristic function to stimulate and provide the rationale for studies, as well as help guide the selection of research questions and variables” (Lenz, 1998, p. 26). Middle range theories also can assist practice by facilitating understanding of client's behavior, suggesting interventions, and providing possible explanations for the degree of effectiveness of the interventions.

Reviews of published studies reveal a fairly extensive use of middle range theory in nursing research. Through the 1990s, it was most often middle range theories from other disciplines (Lenz, 1998) that were used. This was particularly evident when comparing how frequently middle range theories and grand theories of nursing are cited in the nursing research literature. Of 173 studies included in Nursing Research from January 1994 through June 1997, only 79 (45.7%) identified any theory. Of the 79 studies that identified a theory, 25 were nursing theories and 54 were middle range theories borrowed from other disciplines, most frequently from psychology. Of the 25 using nursing theories, middle range accounted for most of the nursing theories used in the studies, 22 of the 25 (Lenz, 1998, p. 27). Though middle range theory has great potential for guiding nursing practice, the nursing literature suggests that the potential has not been fully realized. Many authors note a gap between theory and practice. And when applications of theory to practice are included in the literature, it is more likely to be a grand rather than a middle range theory (Lenz, 1998). An informal survey of ten clinical nurse

specialists and five staff nurses, conducted by Lenz, revealed few who were able to identify theories they were using in their practice. She attributes this to several factors: (1) the busyness of practicing nurses that does not allow time for consideration of the theoretical bases for their actions, (2) educational programs that do not help students learn the connections between theory and practice, (3) clinical environments that do not value theory-based practice, and (4) the lack of availability and usability of information on middle range theories. Nurse theorists need to address the last factor by producing literature describing their theories in understandable terms, identifying the theories' implications for practice, and placing that information in practice-oriented journals. Hospitals need to make use of nursing theory as a means of delivering the best possible patient care. The Magnet Status has supported this endeavor by requiring a professional model of care as one of the components of the Magnet Model®. Frequently, hospitals adopt a specific theory; for instance, Cedars-Sinai Medical Center in Los Angeles integrated Orem's Self-Care Deficit Theory into their shared governance model to improve patient safety (Swanson & Tidwell, 2011). In addition, it is hoped that advance practice nurses, who are increasing in number, will provide the leadership necessary to better integrate nursing theory into practice for the purpose of improving the quality of patient care and outcomes.

Controversy Surrounding Middle Range Theory The identification of middle range theories is not unambiguous. For instance, Chenitz, primary author of Entry into a Nursing Home as Status Passage, labeled it practice theory, whereas others considered it middle range theory (Liehr & Smith, 1999, Analysis of the Middle Range Theory Foundation, para. 2). “The question about what constitutes theory at the middle range is not a black and white issue for which a precise and clear definition can be offered. Middle range theory holds to a given level of abstraction. It is not too broad nor too narrow, but somewhere in the middle” (Liehr & Smith, 1999, Analysis of the Middle Range Theory Foundation, para. 3). To reduce confusion, nurse theorists are encouraged to clearly identify their work as middle range and provide a name that represents its conceptual components (Liehr & Smith, 1999; Sanford, 2000).

The imprecision of what constitutes a middle range theory is only one of several criticisms of middle range theory. In addition to lack of definitional clarity, middle range theory has been criticized for distinguishing itself from grand theories by its ability to be tested, using a logical positivistic idea of testability. Suppe (1996b) suggests an alternative approach to considering the testability of middle range theory. He rejects the widely accepted notion of theories as a set of propositions and proposes the idea that theories are “state-transitions systems modeling the behaviors of real world systems within the theory's scope” (Suppe, 1996b, p. 10). By this conceptualization of theories, operational concepts become descriptors; the values of these concepts become state specifications; and the propositions become specifications of state– transition relations (Suppe, 1996b, p. 11). The purpose of testing using this understanding of the nature of theories is delineating the scope of the middle range theory rather than subjecting a hypothesis to statistical analysis or qualitative data to coding. The basic research question is for what systems does the theory work and for what systems does it not, a question of scope. This type of research question is well suited to the testing of middle range theories.

Since Merton (1968) first promoted the notion of middle range theories, they have been criticized as being intellectually unambitious. Critics argue that their scope and suggested methods of inquiry are too limited. Merton countered that middle range theory was addressing just the questions that the discipline of sociology was asking and that middle range theories can undergo the same systematic empirical testing that both more and less abstract theories can (pp. 63–64).

Another criticism of middle range theories is that their increasing numbers can lead to fragmentation of nursing's knowledge base into unrelated and distinct theories, theories not linked to the philosophical underpinnings of the discipline (Cody, 1999). Merton acknowledged that risk and proposed consolidating theories to create groups of like theories at the middle range (Whall, 1996). Nurse scientists have addressed this issue. The identification of a metaparadigm is an attempt to create some conceptual cohesion for nursing's knowledge base. In addition, there has been an intentional effort to relate middle range theories to nursing's conceptual models, grand theories, and taxonomies. For instance, the middle range theory of Therapeutic Intention is clearly linked to Levine's Conservation Principles. Nurse scientists have proposed anchoring middle range theories to nursing's taxonomies of (1) diagnoses, North American

Nursing Diagnosis Association (NANDA); (2) interventions, Nursing Interventions Classification (NIC); and (3) outcomes, Nursing Outcomes Classification (NOC) (Blegan & Tripp-Reimer, 1997) and have identified a structure to accomplish that linkage (Tripp-Reimer, Woodworth, McCloskey, & Bulechek, 1996). Others consider these taxonomies as types of middle range theories rather than frameworks for categorizing the theories because they consist of concepts, definitions of concepts, propositional statements, and assumptions (Whall, 1996). As taxonomies, these middle range theories could not be considered unrelated and fragmented aspects of nursing's knowledge base. Nurse scientists continue to recommend persistence in efforts to “create an association between the proposed theory and a disciplinary perspective in nursing” (Liehr & Smith, 1999).

Nurse researchers have been denounced for making use of middle range theories from disciplines other than nursing. This was certainly true of nursing research published from the mid-1970s to the mid-1980s. During this period, more than half of the studies made use of theories or models from disciplines other than nursing (Moody et al., 1988). The increasing number of nursing middle range theories is reversing that trend. Liehr and Smith (1999) found 22 middle range nursing theories published in the decade from 1988 to 1999 through a CINAHL search. These theories met a number of criteria, including identification by the author that the theory was of the middle range. The criticism that nurse researchers use middle range theories from disciplines other than nursing is also being addressed by a call to continue to develop theories in the midlevel of scope and abstractness. “Situating middle range theory at the forefront for practice and research is critical to epistemologic and ontologic growth in nursing” (Sanford, 2000, Recommendation 5, para. 1).

Practice Theory/Micro Theory/Situation-Specific Theory The literature includes a confusing variety of terms to refer to the level of theory that is considered less abstract, more specific, and narrower in scope than middle range theory. Practice theory has been the most commonly used term (Jones, 2001; McKenna, 1997; Walker & Avant,

1995). Suppe (1996b), Kramer (1997), and Parker (2006) referred to both practice and micro theory. The term micro theory was also used by Kim (2000), Duldt and Giffin (1985), and Chinn and Kramer (1999, 2005) and by George (1995) and Young et al. (2001), who both cited Chinn and Kramer. The most recently introduced term is situation-specific theory (Im, 2005; Im & Meleis, 1999; Meleis & Im, 2001).

Im and Meleis (1999) argue for this level of theory development, claiming that grand and middle range theories fail to address “the diversities, complexities, and contextual complexities… for which its members [nurses in practice] have been striving” (para. 5). They assert that the grand and middle range theories consist of a wide range of generalizations and universalizations that fail to provided adequate guidance in determining the nursing care for the increasing diverse clients in complex health care systems.

There are a number of features that distinguish these theories from either grand or middle range theories. They exhibit “(1) a lower level of abstraction, (2) reflection of specific nursing phenomena, (3) context, (4) readily accessible connection to nursing research and practice, (5) reflection of diversities in nursing phenomena, and (6) limitation of generalization” (Im & Meleis, 1999, Properties of situation-specific theories, para. 1). A somewhat unique quality of situation-specific theories is their emphasis on sociopolitical, cultural, and historical contexts.

Several authors have provided a list of the necessary components of a practice theory. Dickhoff and James (1968) referred to this goal-oriented theory as “situation-producing” and identified its essential elements as “(1) goal-content specified as aim for activity; (2) prescriptions for activity to realize the goal-content; and (3) a survey list to serve as a supplement to present prescription and preparation for future prescription for activity toward the goal-content” (p. 201).

Jones (2001) interprets these elements to include the use of nursing diagnosis and outcomes classification systems as components of practice theory. Walker and Avant (1995) and Kramer (1997) referred to these three components in their definitions of practice theory and both suggested additional considerations. Walker and Avant claim that without a basis in situation-relating (predictive) theories, it would require a liberal definition of theory to identify practice or situation-producing theory as theory. They suggest that it would be more legitimate to refer to practice theory as nursing practices (pp. 12–13). Kramer identifies a similar issue, the importance of connecting practice theory to the more encompassing

knowledge structures of nursing as identified by metatheory. To the traditional understanding of practice theory, she adds theory about nursing practice (e.g., administrative and educational theories). This is not a commonly occurring use.

Micro theory, a term sometimes identified as interchangeable with practice theory, is included in the writings of Kim (2000), Suppe (1996b), and Chinn and Kramer (2005). Kim's (1983) definition of micro theory as a set of “theoretical statements, usually hypotheses, that deal with narrowly defined phenomena” (p. 13) suggests a research-based theory. Suppe (1996b) also identifies hypothesis testing as a primary feature of micro theories and claims that this feature provides the primary distinction between micro theory and middle range theory, both of which could be considered practice theories (pp. 12–13). According to Suppe, the term micro theory is found with increasing frequency in the literature to refer to theories that are too limited in scope to be considered middle range. He provided a hypothetical example of a micro theory of pain management for a hospitalized patient with acute postamputation pain, who was treated with PCA morphine, with possible Valium potentiation, which focused on pain intensity and addiction outcomes (Suppe, 1996b, p. 12). Kim (1983) provided examples of what she labeled as micro theories, for example, maternal attachment, pressure sores, wound healing, and positioning. Other examples of this level of theory development found in the literature include alcoholism recovery in lesbian women (Hall, 1990), quality of care (Nielson, 1992), milieu therapy for short-stay units (LeCuyer, 1992), caring for patients with chronic skin disease (Kirkevold, 1993), therapeutic touch (Green, 1998), exercise as self-care (Ulbrich, 1999), and ecological view of protection (Shearer, 2002).

Im (2005) proposes situation-specific as the preferred term for this most specific classification of nursing theory. Referring to Jacox, who defined practice theories as those that identify actions that a nurse takes to produce a desired change in a patient's condition, she suggests that all situation-specific theories are practice theories, as are many middle range theories, and some grand theories (pp. 138–139). Situation-specific theories are then defined as “theories that focus on specific nursing phenomena that reflect nursing practice, and are limited to specific populations or to particular fields of practice” (pp. 137–138). Im and Meleis (1999) use the term situation-specific to refer to that level of nursing theory that focuses on specific nursing phenomena with direct application to nursing practice. As noted earlier, a somewhat unique

quality of situation-specific theories is their emphasis on sociopolitical, cultural, and historical contexts, demonstrated by the theory of menopausal transition of Korean immigrant women described by Im and Meleis.

Development of Practice Theory Practice theory can trace its origins to the work of metatheorists Dickhoff and James (1968). Their position, similar to that of Jacox, is that because nursing is a profession, and its theory must have an action orientation that can shape reality to create a desired goal. “The major contention here is that theory exists finally for the sake of practice” (p. 199).

Like other levels of theory, practice theories as situation producing are derived from middle range and grand theories, review of the literature, practice experiences, research, and collaborative efforts. Im (2005) describes an integrative approach, which involves exploring these sources but also includes checking assumptions about theory development, theorizing, and sharing and validating the theory.

Middle range theories can be the source of developing prescriptions directed at a specified goal (McKenna, 1997; Parker, 2006; Walker & Avant, 1995), and if not specifically derived from these middle range theories, at the very least, practice theories should identify how the concepts from both levels of theory are interrelated. Meleis' transition theory (2010) is an example of a middle range theory that has served as a source of multiple practice/situation-specific theories.

Qualitative research, particularly, grounded theory, is often the source of situation-specific theory. The goal of this approach is to explain at a conceptual level a phenomenon (often a process or interaction) developed through an inductive reasoning that is “grounded” in data. The Theoretical Model for Parent–Child Transfer of Asthma Responsibility (Buford, 2004) is an example of this type of theory development.

Analysis of existing research is also an important source of practice theories. Walker and Avant (2011) note the contributions of the Conduct and Utilization of Research in Nursing project in the formulation of practice theories. This project, initiated in 1975, identified a need for change in practice and summarized the relevant research to arrive at research-based principles for nursing interventions. There were ten practice theories or protocols that were considered during the project.

Examples of the protocols that were developed include (1) lactose-free diet, (2) sensation information: distress, (3) intravenous cannula change regimen, and (4) prevention of decubiti by means of small shifts of body weight (Haller, Reynolds, & Horsley, 1979, p. 47).

Examples In current literature for this level of theory development, the term situation-specific is found more frequently than is either practice or micro theory. Table 1.8 provides examples of these theories. Several have used a middle range theory as a foundation of the situation-specific theory, for instance, Meleis' transition theory, and others have used a grounded theory approach.

Table 1.8 Examples of Situation-Specific Theories

Controversy Surrounding Practice Theory In addition to the debate on the term to use in referring to this level of theory, the controversies about practice theory center on whether it further fragments nursing knowledge, whether it is a theory, and, finally if so, whether it is needed. Similar to Cody's (1999) critique of middle range theories, practice theories often fail to identify links to an existing school

of thought, that is, extant grand and middle range theories. These linkages provide for cohesion in the development of nursing science. When efforts are made to establish these relationships, “the resulting practice theory [is elevated] above simple dictates or imperatives for practice” (Walker & Avant, 2011, p. 9). Unfortunately, this occurrence is not routine.

The question of what constitutes a theory is disputable, particularly as it relates to practice theory. Walker (1986) suggests that, based on a definition of practice theory as sets of principles or directives, the terms policy, procedure, or principles of practice might be more appropriate. Her conclusion is based on an understanding of theory as a “systematic description and explanation” (p. 28). Walker's position seems consistent with the increasingly popular phenomena of research utilization and evidence-based practice.

Beckstrand's (1986) contention is that practice theory is unnecessary. She claims that “all the theoretical knowledge relevant to practice can be discovered within existing systems of knowledge such as metatheory, philosophy, science, and ethics.” Collins and Fielder (1986) respond to Beckstrand's conclusion by emphasizing the unique issues that nursing theories must address. They assert that Beckstrand's position does not consider the nurse's responsibility for caring for the client as a “particular” individual. Nursing still has a need for “a nursing theory that will set out the kinds of nursing practice and the particular set of moral ideals that nursing practice seeks to bring about” (Collins & Fielder, 1986, p. 510). The increasing number of practice theories or their semantic equivalent identified in the literature since the 1990s seems to be supporting, if not a need, at least an interest in this level of theory development.

Summary Nurses are inherently knowledge workers with knowledge taking a variety of forms. Theory, research, and practice are inextricably linked in the way nursing knowledge is developed and used. Nursing knowledge exists to define the nature of the profession but more importantly to serve the needs of those in practice. A metaparadigm identifies the concepts of most significance to a discipline and thus provides a means of distinguishing one discipline

from another. For nursing, the four most frequently cited domains of nursing's metaparadigm are person, health, society/environment, and nursing. Nursing knowledge exists on a continuum of abstraction with philosophy/paradigm the most abstract, and conceptual models and theories becoming progressively more concrete. Nursing theories also exist on a continuum with grand theories the most abstract, practice or situation-specific theories the most concrete, and middle range theories in the obvious middle. A theory consists of concepts and propositions that serve to describe, explain, predict, and/or control in relation to a defined phenomenon. Theories can be developed using several processes: analysis, synthesis, and derivation. The sources from which theories are developed include research, practice, and other theories, both nursing and those borrowed from other disciplines. Because middle range theories are general enough to be used across populations and settings but yet focus on a specific clinical phenomenon of interest to nurses, they can be applied to practice and validated through research. The development of nursing knowledge is an ongoing process, though debates continue on the direction this development should take, for instance: (1) Should there be diversity or unity in the paradigmatic perspective of nursing? (2) Can borrowed theories legitimately contribute to nursing's body of knowledge? (3) Without a specific link to nursing's grand theories, is the development of middle range theories further fragmenting the profession's body of knowledge?

Critical Thinking Exercises

1. In the debate on nursing paradigms, which of the currently proposed considerations—emergence of a single paradigm, coexistence of complementary paradigms, or creation of an integrated paradigm from the two most prominent paradigms—seems to best serve the advancement of nursing knowledge? What would be the implications of the chosen perspective on paradigms for the development of nursing knowledge?

2. Make a case for the ongoing development and use of nursing grand theories. Conversely, make a case for the obsolescence of nursing grand theories for today's practice and research.

3. Identify a research topic or develop a research question. Refer to Table 1.6, Examples of Middle Range Theories. Which middle range theory might be applicable to the research topic or question? If none seems appropriate, why might that be?

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2 Analysis, Evaluation, and Selection of a Middle Range Nursing Theory

Timothy S. Bredow

Definition of Key Terms

Adequacy Determines how completely the theory addresses the topics it claims to address. Establishes if there are holes or gaps that need to be filled in by other work or further refinement of the theory. Addresses if the theory accounts for the subject matter under consideration

Clarity Addresses if the theory clearly states the main components to be considered. Determines if it is easily understood by the reader

Complexity Reviews how many concepts are involved as key components in the theory. Decides how complicated the description of the theory is, and if it can be understood without lengthy descriptions and explanations; considers the number of variables being addressed and exists on a continuum from parsimony—limited

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number of variables to complex—extensive number of variables

Consistency Addresses whether the theory maintains the definitions of the key concepts throughout the explanation of the theory. Determines if it has congruent use of terms, interpretations, principles, and methods throughout

Discrimination Addresses whether the hypothesis generated by the theory led to research results that could not be arrived at using some other nursing theory. Determines how unique the theory is to the area of nursing that it addresses. Decides if it has precise and clear boundaries and definitive parameters of the subject matter

External criticism Considers the fit between the theory and criteria external to the theory, such as the social environment and the prevailing views on the nursing metaparadigm. Criticism here is dependent on individual preference. It depends on reasonableness and perceptions of the evaluator.

Internal criticism Deals with the criteria concerning the inner workings (internal dimensions) of the theory and how the theory's components fit with each other

Logical development Resolves the following questions: Does the theory logically follow a line of thought of previous work that has been shown to be true or does it launch out into unproven territory with its assumptions and premises? Do the conclusions proceed in a logical fashion? Are the arguments well supported?

Nursing metaparadigm Global concepts that identify the phenomena of nursing, including person, environment, health, and nursing (Fawcett, 1995)

Pragmatic Determines if the theory can be operationalized in real-life settings

Reality convergence Determines if the theory's underlying assumptions ring true. Decides if the theory's assumptions represent the real world, and if it represents the real world of nursing. Does the theory reflect the real world as understood by the reader?

Scope Determines how broad or narrow is the range of phenomena that this theory covers. Does it stay in a narrow range of

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scope to keep it a middle range theory? (Narrower implies more applicable to practice; wider implies more global and all- encompassing.)

Significance Will the result of the research that is conducted because of the hypotheses generated by the theory have any impact on the way nurses carry out nursing interventions in the real world, or does it merely describe what nurses do? Does the theory address essential, not irrelevant, issues to the discipline?

Theory analysis Systematic examination of exactly what was written by the theory author(s)

Theory evaluation The identification of component parts of a theory and the judgment of them against a set of predetermined criteria

Utility Determines if the theory can be used to generate hypotheses that are researchable by nurses

Introduction Middle range nursing theories can help nurses and graduate nursing students alike meet and accomplish their goals of carrying out sound nursing research. When nursing theories are analyzed and evaluated in a thorough, systematic fashion, it is easier to determine which middle range nursing theory will provide the proper guidance and direction for the research under consideration. This chapter should help graduate student nurses and research nurses deal with the problem of how to analyze, evaluate, and choose a middle range nursing theory for their assignments, and apply it to their research interests.

Theory analysis is the systematic examination of what was personally written over time by the theory author(s) about the theory. When performing a middle range theory analysis, the component parts are identified and the relationships of these components to each other and to the whole theory are examined. This analysis can provide the nurse researcher a thorough understanding about the theory. Theory evaluation is the identification of the theory's same components and judging them

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against a set of predetermined criteria. The criteria used for judging theories are not standardized within the field of nursing but, rather, have evolved over time and are different depending on who is presenting the evaluation. Nonetheless, a thorough evaluation of a middle range theory will help the nurse researcher determine the robustness of the theory and the goodness of fit for application to a particular research project.

Over the years, nursing theorists have emerged with different theoretical positions and theories proposing how various nursing concepts and the nursing metaparadigm are uniquely linked. Most of these theorists have constructed theories of nursing that could be termed grand theories, while later theorists have constructed middle range nursing theories. There are now more than 50 different grand nursing theories (McKenna, 1997) and several dozen middle range nursing theories for nursing researchers to choose from.

Historical Background Historically, nursing theorists worked hard to explain the nature of nursing, carving out a differentiated scientific field to call their own. At the same time, nursing researchers wanted nursing theory to be constructed to aid the generation of testable research hypotheses and also have the ability to affect the practice of nursing. As nursing theory developed and progressed through different stages of maturity, so did the evaluation process of what constitutes sound nursing theory.

In the past, nurses had Nightingale's environmental model, the medical model, and borrowed theories to use as a basis for nursing research. Through the 1960s, 1970s, and 1980s, several different grand nursing theories and some middle range theories were developed for nurses to use as a basis for their research. In the 1990s and beyond, many more middle range theories have emerged, allowing nurses to move away from using the Nightingale model, the medical model, borrowed theories, and grand nursing theories. When compared to grand theories, middle range theories contain fewer concepts, with relationships that are adaptable and concrete enough to be tested. Middle range theories have a particular substantive focus and consider only a limited aspect of reality. For example, Orem's Self-Care Deficit grand nursing theory would consider patients who are unable to carry out the activities of daily living and provide nursing care

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necessary to aid them back to a level of living where they were able to provide self-care. The middle range theory of unpleasant symptoms would use this same situation and consider the actual unpleasant symptom that was causing the problem for the patient. It would address the patient's symptom as a consideration for a multidimensional approach to health care symptom management. Kolcaba states that “for these reasons middle range theories are particularly cogent as nursing science addresses the challenges of the 21st century” (2001, p. 86). The use of many different middle range nursing theories for research purposes became a relatively new and exciting possibility for nurses during the 1990s. Now, researchers are expanding the knowledge base of nursing by enhancement of nursing's frameworks and theories (Parse, 2001). Because of this evolutionary process of theory building, nurses need to understand the historical roots for the analysis and evaluation of grand and middle range nursing theories. In addition, understanding the process of analysis and evaluation provides insight to the evaluator about the strengths and weaknesses of the individual theory itself, as well as its possible use and application to nursing research and practice.

Meleis (1997, p. 245) states that “nurses have always evaluated theories.” She provides the reasons why evaluation of theory is an essential component of nursing research:

To decide which theory is more appropriate to use as a framework for research To identify effective theories for guiding a research project To compare and contrast different explanations of the same phenomenon To identify epistemological approaches of a discipline through attention to the sociocultural context of the theorist and the theory To assess the ontological beliefs and schools of thought in a discipline To define research priorities (Meleis, 1997)

Theory Analysis

Theory Analysis by Early Authors

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The analysis of nursing theory has evolved over time as nurses have proposed increasingly sophisticated methods for reviewing and analyzing nursing theory. Three “early approaches” to theory analysis by Duffy and Muhlenkamp, Hardy, and Chinn and Jacobs will be discussed followed by a discussion of “recent approaches” by Barnum, Meleis, and Fawcett.

Duffy and Muhlenkamp (1974) wrote that nursing theory should be examined using four distinct questions. They suggested looking at the origin of the problem, the methods used in the pursuit of knowledge, the subject matter, and the kind of outcomes of testing generated by this theory.

These four questions when used alone to examine a nursing theory provided a fairly good evaluation of the theory; however, additional evaluation questions were proposed when the theory was used for research. Their additional questions for analyzing a nursing theory for nursing research included the following:

Does it generate a testable hypothesis, and is it complete in terms of subject matter and perspective? Are the biases or values underlying the theory made explicit? Are the relationships among the propositions made explicit, and are they parsimonious?

With all of these questions in hand, a nurse could do what was thought, at the time, to be a thorough and complete assessment of any particular nursing theory to be used for nursing research.

During the same period of time, Hardy (1974) developed another way to analyze nursing theories. Her analysis method contained some unique criteria when compared to Duffy and Muhlenkamp's and included more criteria related to the process and outcome of theory evaluation. Her evaluation criteria identified the need for the theory to have adequacy, meaning, logic, and pragmatism. She wanted the theory to provide empirical evidence, have the ability to be generalized, contribute to further understanding, and be able to predict outcomes.

These two positions within the same historical time period contain some unique as well as overlapping criteria for the analysis and evaluation of nursing theory.

In the 1980s, Chinn and Jacobs (1983) proposed a combination of the previous two positions and recommended five brief criteria for evaluating nursing theories. They stated that a theory could be evaluated by asking if

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it had clarity, simplicity, generality, empirical applicability, and consequences. Clarity was further expanded to include semantic clarity, semantic consistency, structural clarity, and structural consistency. Apparently, they felt that semantics and clarity were becoming issues in the nursing community, and they were attempting to address these particular issues.

Recent Approaches to Theory Analysis In addition to consideration of criteria for evaluation of theories, nursing theorists have proposed steps for the analysis process of nursing theories. Barnum, Meleis, and Fawcett all present several steps for the analysis of a nursing theory.

Recognizing the underlying assumptions of a theoretical work is an analyst's first task in understanding the theory (Barnum, 1998; Meleis, 1997). These assumptions may not be stated but may be inferred by the reader on the basis of other statements made about the given nursing theory in other publications and writings. However, recognizing underlying assumptions may not be possible for some middle range theories, because many of these middle range theories are not constructed by any one particular nursing author but are the work of multiple authors. It then becomes difficult to understand all of the different assumptions from a variety of publications written by them. In addition, not all middle range theories are named after some nursing author or even have a particular author's name attached to the theory. For example, most of the middle range theories contained in this text do not have a theorist name attached to them, yet they have proved useful in the furtherance of nursing understanding. In addition, there are middle range theories such as Quality of Life or Reasoned Action that are borrowed from other disciplines unrelated to nursing but are used by nurses to describe and build the understanding of nursing. Nonetheless, there are some middle range theories that do have information available about the underlying assumptions, and for them, it is important to understand and relate these assumptions to the research problem.

Barnum (1990, p. 22) asserts that analysis of a theory demands that the analyst “dig beneath the surface for a deeper insight into a thesis in all its meaning and implications.” This “reading between the lines” work may be difficult for some nurses because they may not be comfortable with

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criticism at this level. Meleis (1997) would like to see reviews of theorists; their education, experience, and professional network; and the sociocultural context of their theories. Because theory development in nursing did not take place in a vacuum, Meleis (1997) feels that it is important to carefully consider the paradigmatic origins of the theory through careful analysis of the references and citations cited by the author. In addition, she wants the analysis to include a thorough review of the assumptions, concepts, propositions, and hypothesis that the author employed, and she wants the theory to be examined for beginnings. Analysis of beginnings looks at where the theory started. Did it begin in the mind of the theorist as an attempt to explain what ought to be, or did it arise out of experience and explain what it is? Fawcett (1995) suggests that analysis needs to include a thorough review of all the author's original works and presentations. However, for some middle range theories, because they are relatively new to the field of nursing, there may not be enough published work produced by a particular author or group of authors for the analyst to read and grasp this level of understanding about the theory's meaning and implications.

Barnum believes that the analyst should determine who or what performs an activity within the theory, as well as to determine who or what is the recipient of the activity. A third area that should be evaluated in each theory is in what context the activity is performed and what the end point of the activity is. Two additional concepts that need to be addressed include the procedures that guide the activity and the energy source of the activity. Other concepts Barnum considered essential for theory analysis include nursing acts, the patient, and health (1998). Also included for good theory analysis are the relationship of nursing acts to the patient, the relationship of nursing acts to health, and the relationship of the patient to health. These concepts from Barnum are closely associated with the nursing metaparadigm that includes the concepts of nursing, person, health, and environment.

Barnum presents several devices for theory analysis. These devices use common nursing concepts to define nursing theory elements and their interrelationships. They also include determination of the level of theory development, descriptive or explanatory, and the need to discriminate nursing acts from nonnursing acts. Barnum (1990) adds that every nursing theory is based upon one or more dominant principles. These dominant principles contain an idea that is essential for stating or explaining a theory. It is important to identify and consider the nature of each key

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principle. A principle is a fundamental or basic concept with an explanatory function. It explains the basis upon which the theory rests. The theorist's interpretation of reality, if it is given, should be analyzed by asking, “What is reality like?” Many of these considerations were geared toward the analysis of grand theories and have to be adapted for use when considering middle range theories. For example, if a middle range theory has been formulated over time by several authors, then it will be difficult, if not impossible, to determine the theorist's interpretation of reality.

Meleis includes internal dimensions as a criterion of her method of theory analysis. Internal dimensions include assumptions and concepts upon which the theory is built. She includes several units of analysis as part of this inquiry. Her units of analysis include content, context, and methods and are similar to the units of analysis contained in Barnum's list. Other items unique to Meleis include the rationale, the system of relations, beginnings, scope, goals, and abstractness. Examining the rationale of a theory's construction provides clarification of how the elements of the theory are united. Meleis wants the analyst to discover the theory's system of relations. This is accomplished by asking the question, “Do relations explain elements or do the elements explain relations?” (Meleis, 1997, p. 258). The scope of a theory determines how broad or narrow is the range of phenomena that the theory covers. Middle range theories keep their scope narrow, helping to make the theory more applicable to research and practice. The scope of a theory also deals with the breadth of the explanations it attempts to accomplish. The scope is narrower, more specific, and more concrete for middle range theories than it is for grand theories (Fawcett, 1999).

The goals of a theory also need to be examined. Does the theory attempt to describe, explain, predict, or prescribe? Each theory must attempt to accomplish at least one of these goals. Middle range theories can be classified as falling into three distinct categories. These categories are descriptive, explanatory, and predictive (Fawcett, 2000). These three categories are closely aligned with the definition given by Meleis (1997) for a grand theory that includes describing, explaining, and predicting different phenomena.

Abstractness is another point that Meleis says is necessary to examine when analyzing a theory. Analyzing abstractness is an attempt to determine the width of the gaps between the theories, propositions, concepts, and reality. In middle range theories, this gap should be small, or nonexistent, since middle range theories deal with what is and not with

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what ought to be. Fawcett (2000) has several recommendations for theory analysis that

are similar to Meleis' and Barnum's. She has two additional components to consider. They are theory context and theory content. Theory context is the environment in which the theory's nursing action takes place. It tells about the nature of the nurses' world and may describe the nature of the client environment. Theory context is also concerned with which nursing metaparadigm concepts are addressed by the theory (Fawcett, 2000). In middle range theories, the focus of the theory may be purposefully limited to just one of the nursing metaparadigm concepts, such as in pain theory.

Theory content identifies the theory elements that are the subject matter of the theory. The content is stated through the concepts and propositions (Fawcett, 2000). Middle range theories should have their content well defined and their concepts clearly stated in the description of the theory.

A theory's process refers to the activities that either the nurse or the client has to perform to implement the theory. This should be the strength of middle range theories as they give clear direction to some process or activity carried out in the application of the theory in research or practice.

Theory Evaluation

Barnum's Theory Evaluation Recommendations Barnum (1990, p. 20) states that “a thorough criticism (both analysis and evaluation) of a theory requires that attention be given to both aspects of internal and external criticism.” Internal criticism refers to the internal construction of how the components of the theory fit together, while external criticism considers the theory and its relationship to people, nursing, and health. Internal criticism requires the reviewer to answer the following questions:

Given the theorist's underlying assumptions, does the theory logically follow?

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Is the theory consistent with and logical in light of the underlying assumptions?

For external criticism, the reviewer would ask the following questions:

Do the theory's underlying assumptions ring true? Do the assumptions represent the “real world” out there, especially the real world of nursing?

Barnum's criteria for evaluating theories include both internal and external criticism based on specific criteria. Her criteria for judging theories for internal criticism include clarity, consistency, adequacy, logical development, and level of theory development. Her criteria for judging theories using external criticism include reality convergence, utility, significance, discrimination, scope of theory, and complexity (Barnum, 1998).

Internal criticism is first evaluated by deciding the clarity of the theory. Two questions should be answered to determine clarity:

Does the theory clearly state the main components to be considered? Is it easily understood by the reader?

Next on Barnum's list is consistency. Two more questions help to determine if the theory is consistent:

Does the description of the theory continue to maintain the definitions of the key concepts throughout the explanation of the theory? Does it have congruent use of terms, interpretations, principles, and methods?

The next criterion is adequacy. Three questions help to determine if the theory is adequate:

How completely does the theory speak to the topics it claims to address? Are there holes or gaps that need to be filled in by other work or further refinement of the theory? Does it account for the subject matter under consideration?

Her fourth criterion is logical development. The quality of this criterion is determined by asking three questions:

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Does the theory logically follow a line of thought of previous work that has been shown to be true or does it launch out into unproven territory with its assumptions and premises? Do the conclusions proceed in a logical fashion? Are the arguments well supported?

The final criterion for evaluating the internal portion of the theory is the level of theory development, which can be determined by asking the following questions:

Is it in early development, just at the stage of naming its elements, or has it been around a long time and is able to explain or even predict outcomes? How often have different nurse researchers conducted independent research studies applying the theory to different situations and reported the findings in the literature?

Barnum (1998, p. 178) states that “external criticism evaluates a nursing theory as it relates to the real world of man, of nursing, and of health.” She recommends that the following criteria should be considered: reality convergence, utility, significance, and capacity for discrimination. In addition, two other criteria may be included: scope and complexity (Barnum, 1998).

Reality convergence deals with how well the theory builds upon the premises from which it is derived and then relates that to reality. Some nursing theorists build on past work and remain within the framework of traditional thinking. Other nurse theorists deconstruct the past and develop a new framework to build upon. These theorists are termed deconstructionists. Deconstructionists start with a different set of presuppositions than the historical nursing leaders did, and the resulting nursing theories may not represent the same worldview of nursing as described in the past. At this point, the person doing the evaluation may choose to disagree as to whether a particular theory achieves reality convergence, based primarily on the differences between the beliefs and the values that he or she holds to be true and those proposed by the theory. This part of theory evaluation may have more applicability to grand theories than middle range theories but is an important point to consider, as new and different middle range theories are developed in future.

Utility simply requires that the theory be useful to the nurse researcher employing it. It should suggest subject material that could be investigated

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and lend itself to methods of inquiry. Middle range theories generally lend themselves to a greater ease of usefulness by nurse researchers than do grand nursing theories. This is because they tend to be very narrow in scope and focused on specific concepts, like health promotion, pain, and quality of life.

The significance of a nursing theory depends upon the extent to which it addresses the phenomena of nursing and lends itself to further research.

Discrimination is the capacity to differentiate nursing from other health-related disciplines through the use of well-defined boundaries. The boundaries need to be clear and precise so that judgments can be made about any given action performed by a nurse.

Barnum includes the scope of a theory as a necessary criterion for external criticism. Important questions to consider here are, does it have a narrow range of scope to help identify it as a middle range theory and does that narrow focus make it easier to use in a research setting?

Complexity is the final criterion in Barnum's list. Complexity is at the opposite pole from the criterion of parsimony. The level of complexity is determined by the number of variables. Middle range nursing theories are less complex than are grand nursing theories because they deal with fewer variables, resulting in a fewer number of relationships between the concepts.

Meleis' Theory Evaluation Recommendations Meleis (1997) provides a complex model for theory evaluation. It includes several integral parts: theory description, theory support, theory analysis, and theory critique. She proposes that this complete model represents the necessary elements needed to thoroughly evaluate a theory. Meleis begins the description of her model by listing two criteria that help describe the theory. These two criteria are structural and functional components. Within the criterion of structural components, there are separate units of analysis to consider. The first is assumptions. Assumptions are “givens” in the theory and are based on the theorist's values. They are not subject to testing but lead to the set of propositions that are to be tested. In nursing theories, there are many assumptions made about the concepts included in the nursing metaparadigm and, additionally, to the concepts of human

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behavior, life, death, and illness. Again, it must be stated that it will not be possible to find the assumptions of all middle range theories.

Another part of Meleis' theory description includes functional components. A functional assessment of a theory carefully considers the anticipated consequences of the theory and its purposes. The units of analysis of the functional components are the theory's focus, that is, the client, nursing, health, nurse–patient interactions, the environment, nursing problems, and nursing therapeutics (p. 251).

Meleis offers several questions to ask when considering the functional components of a nursing theory (p. 254). They include the following:

1. Whom does the theory act upon? 2. What definitions does the theory offer for the elements of the nursing

metaparadigm? 3. Does the theory offer a clear idea of what the sources of nursing

problems are? 4. Does the theory provide interventions for nurses? 5. Are there guidelines for intervention modalities? 6. Does it provide guidelines for the role of the nurse? 7. Are the consequences of the nurse's actions articulated?

Meleis feels that these criteria are consistent with the ones offered by Barnum.

Another major area of theory evaluation for Meleis is theory support. She includes theory testing in this area. Theory testing consists of four separate tests: tests of utility, tests of nonnursing propositions, tests of concepts, and tests of propositions.

A final area of evaluation in the model is what Meleis calls theory critique. Theory critique is made up of several criteria. Many of her criteria are similar to the ones developed by Barnum, but some are unique to Meleis. The duplicated criteria similar to Barnum's are clarity, consistency, simplicity/complexity, and usefulness. Some unique criteria are tautology/teleology and diagrams.

Tautology considers evaluating the needless repetition of an idea in separate parts of the theory. Overuse of repetition can confuse a reader and make the theory explanation unclear.

Teleology is assessed by considering the extent to which causes and consequences are kept separate in the theory. Meleis (1997) says teleology

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occurs when the theorist defines concepts by consequences and then introduces totally new concepts, rather than getting to the definitions of the original concepts. As this process continues, there is never a clear definition of the theory's concepts, and the theory remains unclear.

Diagrams are useful to visually see the interrelationship of the concepts to each other before doing research. They can be especially useful for reviewing the strength of statistical correlations between the theory's concepts.

Fawcett's Theory Evaluation Recommendations Fawcett (2000) made the following recommendations to be used for the evaluation of nursing theories. Her criteria include significance, internal consistency, parsimony, testability, empirical adequacy, and pragmatic adequacy. She also recommends that the evaluation of a theory requires judgments to be made about the extent to which a theory satisfies the criteria.

Significance may be determined by asking the following questions: Are the metaparadigm concepts and propositions addressed by the theory explicit? In middle range theories, all aspects of the metaparadigm for nursing are not always covered, and that should not detract from its use by nursing researchers. Are the philosophical claims on which the theory is based explicit? Here again, some middle range theories will be devoid of philosophical claims. Is the conceptual model from which the theory was derived explicit? Are the authors of antecedent knowledge from nursing and adjunctive disciplines acknowledged, and are bibliographical citations given? (Fawcett, 2000, p. 504).

Fawcett's second criterion of internal consistency requires that all the elements of the theory be congruent. These elements may include conceptual model and theory concepts and propositions. In addition, Fawcett suggests that semantic clarity and consistency are required for internal consistency to be maintained. She proposes that the following questions be asked when evaluating the internal consistency of a theory: Are the content and the context of the theory congruent? Do the concepts reflect semantic clarity and consistency? Do the theory propositions reflect structural consistency? (Fawcett, 2000).

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Parsimony is concerned with whether the theory is stated clearly and concisely. This criterion is met when the statements clarify rather than obscure the topic of interest. This is as important in middle range theory as it is in grand theory. Even though the scope of the theory may be narrow in a middle range theory, it is still important to be clear and concise in the explanations of the concepts.

The goal of theory development in nursing is the empirical testing of interventions that are specified in the form of middle range theories (Fawcett, 2000). The concepts of a middle range theory should be observable and the propositions measurable. Fawcett (2000, p. 506) suggests that the following questions should be asked when evaluating the testability of a middle range theory: Does the research methodology reflect the middle range theory? Are the middle range theory concepts observable through instruments that are appropriate empirical indicators of those concepts? Do the data analysis techniques permit measurement of the middle range theory propositions?

Empirical adequacy is the fifth step that Fawcett says is necessary in the evaluation of nursing theories. This step requires that assertions made by the theory are congruent with empirical evidence found through studies done using the theory as a basis for research. It usually takes more than one research study to establish empirical adequacy. The end result of using empirical adequacy is to establish the level of confidence in the theory from the best studies yielding empirical results. The question to be considered here is, are the middle range theory's assertions harmonious with the research studies' empirical results?

The final and sixth step in Fawcett's framework for evaluation of nursing theories is the criterion of pragmatic adequacy. This criterion evaluates the extent of how well the middle range theory is utilized in clinical practice. The criterion also requires that nurses fully understand the full content of the theory. In addition, the theory should help move resulting nursing action toward favorable client outcomes. Ask the following questions when evaluating a theory for pragmatic adequacy:

Do nurses need special education and skill training to apply the theory in clinical practice? Is it possible to derive clinical protocols from the theory? How often has the theory been used as the basis of nursing research? Do favorable outcomes result from using the theory as a basis for nursing actions? (Fawcett, 2000)

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Fawcett and Garity (2009) revised and updated Fawcett's (2000) recommendations for evaluating middle range theories in their book Evaluating Research for Evidence-Based Practice. In this textbook, they present four key areas to evaluate middle range theories. They outline four areas to consider: significance, internal consistency, parsimony, and testability.

Significance is broken down into two parts to consider: social significance and theoretical significance. Social significance is concerned with the theory's impact on the subject's lifestyle. Theoretical significance is concerned about the theory offering a new insight into people's experience with a certain health condition.

Internal consistency is related to the theory's concepts being operationally and conceptually defined. Semantic consistency is stated as being part of internal consistency and is concerned that all of the concepts used in the middle range theory are used consistently throughout the description and discussion of the theory. The last part of internal consistency is structural consistency. This part is concerned that all of the propositions of the theory are reasonable and that they are organized in such a way that reasonable conclusions can be reached.

Parsimony is concerned with the conciseness with which the theory is explained.

Testability is concerned that each concept used in the theory is observable and thus testable. This area of evaluation asks if the theory has ever been tested with a research study. If so, has the data been analyzed through some reasonable data analysis?

Kolcaba's Theory Evaluation Recommendations A recent contribution to this discussion of theory evaluation comes from Kolcaba. According to Kolcaba (2001), there are several criteria that determine a good middle range theory. Her criteria involve evaluation and do not mention steps for theory analysis. They include questions concerning the theory's concepts and propositions and whether or not they are specific to nursing. She also wants to determine if the theory has components that are readily operationalized and can be applied to many situations. She asserts that a middle range theory's propositions can range

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from causal to associative, depending on their application. The assumptions provided fit the middle range theory. The theory should be relevant for the potential users. The middle range theory should be oriented to outcomes that are important for patients and not merely describe what nurses do. Finally, Kolcaba thinks that middle range theory should describe nursing-sensitive phenomena that are readily associated with the deliberate actions of nurses.

An interesting review process of the Synergy Middle Range Theory (see Chapter 5, Synergy Model) took place during its development. A committee of experts in the analysis of theoretical and conceptual frameworks was assembled to review this theory in order to identify its strengths and weaknesses and to obtain recommendations regarding the refinement of the model (Sechrist, Berlin, & Biel, 2000). This review committee was made up of the following nurse leaders: Barbara Stevens Barnum, RN, PhD; Marion Broome, RN, PhD; Rose Constantino, RN, PhD; Jacqueline Fawcett, RN, PhD; Edna Menke, RN, PhD; Carolyn Murdaugh, RN, PhD; Patricia Moritz, RN, PhD; Bonnie Rogers, DPH, COHN-S; and Marilyn Frank-Stromborg, EdD, JD, ANP. This esteemed committee developed a review instrument that was organized into six criteria. These criteria included the headings of clarity, consistency, adequacy, utility, significance, and summary. When compared to the recommended criteria listed in this chapter, the expert review committee decided to evaluate the synergy theory on fewer criteria. Their evaluation left out “logical development” and “determining the level of theory development” in the appraisal of internal theory analysis. When determining which criteria to include for the external middle range theory analysis, they chose to reduce the list to just three criteria, leaving out complexity, discrimination, reality convergence, pragmatic, and scope. They did add one new criterion, which may act as a “catch all” for the criteria left out, which they called the summary. In a PowerPoint presentation that was posted on the World Wide Web, Fawcett has suggested an even smaller set of criteria to evaluate middle range theories. Her list is short and includes just four total criteria: significance, internal consistency, and two new criteria, parsimony and testability (Fawcett, 2005).

It is evident that there are several distinct differences between the analysis and evaluation process for grand theories and middle range theories. At the same time, there are several similarities. Many of the principles applied to the analysis and evaluation of grand theories can be

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readily applied to middle range theories and, with some minor modification, can be used to determine the adequacy of a middle range theory. With this in mind, the next section will address the selection of a middle range theory for use in nursing research.

Selecting a Theory for Nursing Research Before starting to write a proposal, Fawcett (1999) suggests that each investigator become familiar with the research topic and the conceptual model that will guide the study. She reiterates that this is done by an immersion into the literature and a thorough study of the research topic. In addition, a comprehensive literature search should be done several months before making a proposal of the study. This much time must be given to allow the proper amount of time for reading and thinking about both the content of the proposed study and the conceptual model to provide the basis for the study. It is during this time that the most appropriate middle range theory can be decided upon for use in the research.

As nurse researchers shift away from using grand nursing theories and begin to consider using middle range theories, the philosophical underpinnings of the theory itself become of decreased importance. The emphasis shifts from the philosophical basis of the nursing theory to how the middle range theory is applied in research and practice. Thus, time previously spent with the philosophy and background of the theorist can now be devoted to ensuring the proper fit between the research questions to be studied and the middle range theory. Each nurse researcher should ask the following questions about the middle range theory proposed for use in his or her research:

Does the theory seem to fit the research that you wish to do? Is it readily operationalized? What has been the primary application for this theory in the past? Where has the theory in question been applied and used before? How well has the theory performed at describing, predicting, and/or explaining the phenomena that it relates to? Does the theory relate to and address the research hypothesis in its description and explanation?

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Does the hypothesis flow from the research problem? Does the theory address the primary and secondary research questions? Are the theory's assumptions congruent with the assumptions that are made for this research? Is it oriented to outcomes that are critical to patients and does not describe what nurses perform? Are tools available to test relationships of the theory or do they need to be developed?

The nurse researcher should consider several different middle range theories as possibilities for use. A thorough analysis and evaluation of these theories in question should be done before selecting one. Subsequently, the nurse researcher should become familiar with all aspects of the theory, using the questions provided in the discussion above. It is essential to have a sound understanding and be in total agreement with the theory selected before beginning the study. This is accomplished by becoming immersed in the literature about the middle range theory in question and arriving at a thorough and complete understanding of the theory before using it. The nurse researcher should try to understand the middle range theory by identifying all the major concepts. The definitions of these concepts, in turn, should be studied for this particular theory, to make sure that the meanings have not been changed slightly over time as they are described in the literature.

In addition, the major concepts should be examined to determine how they relate to each other. Next, the researcher needs to decide if he or she can accept the premises, rationale, and presuppositions that the nursing theory is based upon before adopting it for use (McKenna, 1997). Finally, it is necessary to determine what means of measurement have been used with previous studies employing this theory. It will be important to know if new measurement tools need to be obtained or if similar tools can be employed for the study at hand.

It is evident that to decide upon and use a middle range theory effectively in nursing research, the potential nurse researcher must do a thorough analysis and evaluation of the middle range nursing theory. The following section will provide the guidance for conducting an evaluation of a middle range theory before selecting it for use in a research study.

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Middle Range Theory Evaluation Process Before determining if a middle range theory is appropriate for use in a research study, apply both internal and external criticism. After careful review of the theory, take into account the following criteria listed here with their definitions. Answer the questions posed for each criterion. Summarize the findings in a concluding paragraph for both internal and external criticism. Finally, make a judgment as to whether the theory could be adapted for use in research.

There are analyses of theory exercises for many of the theories found in this book that are available on Web site. After completing the exercise, compare your conclusions about the theory with a nurse who has worked with the theory and completed an analysis.

Internal Criticism Adequacy: How completely does the theory address the topics it claims to address? Are there holes or gaps that need to be filled in by other work or further refinement of the theory? Does it account for the subject matter under consideration? Clarity: Does the theory clearly state the main components to be considered? Is it easily understood by the reader? Consistency: Does the description of the theory address whether it maintains the definitions of the key concepts throughout the explanation? Does it have congruent use of terms, interpretations, principles, and methods? Logical development: Does the theory logically follow a line of thought of previous work that has been shown to be true, or does it launch out into unproven territory with its assumptions and premises? Do the conclusions proceed in a logical fashion? Are the arguments well supported? Level of theory development: Is it consistent with the conceptualization of middle range theory?

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External Criticism Complexity: How many concepts are involved as key components in the theory? How complicated is the description of the theory? Can it be understood without lengthy descriptions and explanations? (Considers the number of variables being addressed and exists on a continuum from parsimony—limited number of variables to complex—extensive number of variables) Discrimination: Is this theory able to produce hypotheses that will lead to research results that could not be arrived at using some other nursing theory? How unique is this theory to the area of nursing that it addresses? Does it have precise and clear boundaries and definitive parameters of the subject matter? Reality convergence: Do the theory's underlying assumptions ring true? Do these assumptions represent the real world? Do they represent the real world of nursing? Does the theory reflect the real world as understood by the reader? Pragmatic: Can the theory be operationalized in real-life settings? Scope: How broad or narrow is the range of phenomena that this theory covers? Does it stay in a narrow range of scope to keep it a middle range theory? (Narrower implies more applicable to practice; wider implies more global and all-encompassing.) Significance: Will the result of the research that is conducted because of the hypothesis generated by the theory have any impact on the way nurses carry out nursing interventions in the real world, or does it merely describe what nurses do? Does the theory address issues essential, not irrelevant, to the discipline? Utility: Is the theory able to be used to generate hypotheses that are researchable by nurses?

Critical Thinking Exercises

1. Recently, groups of nurses and nurse theorists alike have migrated to an abbreviated process for middle range theory analysis. What information about the theory is not available from this abbreviated review?

2. Do you think that the shorter method of analysis results in a “good

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enough” analysis of any one middle range theory? Why or why not? 3. If you were going to use a particular middle range theory for your

own research study, would you be satisfied with the abbreviated method of analysis before you begin the project?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and Analysis of Theory exercises for selected theories.

REFERENCES Barnum, B. (1990). Nursing theory, analysis application, evaluation (3rd

ed.). Glenview, IL: Scott, Foresman, Little Brown. Barnum, B. (1998). Nursing theory: Analysis, application and evaluation

(5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Chinn, P., & Jacobs, M. (1983). Theory and nursing: A systematic

approach. St. Louis, MO: Mosby. Duffy, M., & Muhlenkamp, A. (1974). A framework for theory analysis.

Nursing Outlook, 22(9), 570–574. Fawcett, J. (1995). Analysis and evaluation of conceptual models of

nursing (3rd ed.). Philadelphia, PA: F.A. Davis. Fawcett, J. (1999). The relationship of theory and research (3rd ed.).

Philadelphia, PA: F.A. Davis. Fawcett, J. (2000). Analysis and evaluation of contemporary nursing

knowledge: Nursing models and theories. Philadelphia, PA: F.A. Davis.

Fawcett, J. (2005). Evaluating conceptual-theoretical-empirical structures for science of unitary human beings-based research. Retrieved July 2005 from http://medweb.uwcm.ac.uk/martha/Repository/Fawcett2005.ppt#398,1

Hardy, M. (1974). Theories: Components, development, evaluation. Nursing Research, 23(2), 100–107.

Kolcaba, K. (2001). Evolution of the middle range theory of comfort for outcomes research. Nursing Outlook, 49(2), 86–92.

McKenna, H. (1997). Nursing theories and models. London, UK: Routledge.

Meleis, A. (1997). Theoretical nursing: Development and progress (3rd

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http://medweb.uwcm.ac.uk/martha/Repository/Fawcett2005.ppt#398,1

ed.). Philadelphia, PA: Lippincott-Raven. Parse, R. (2001). Rosemary Rizzo Parse the human becoming school of

thought. In M. Parker (Ed.), Nursing theories and nursing practice. Philadelphia, PA: F.A. Davis.

Sechrist K., Berlin, L., & Biel, M. (2000). The synergy model: Overview of theoretical review process. Critical Care Nurse, 20(1), 85–86.

BIBLIOGRAPHY Alligood, M. R., & Marriner-Tomey, A. M. (2002). Nursing theory:

Utilization and application (2nd ed.). St. Louis, MO: Mosby. Barns, B. (1999). Nursing theories' conceptual and philosophical

foundations. New York, NY: Springer Publishing Company. Chinn, P., & Kramer, M. (1995). Theory and nursing: A systematic

approach (4th ed.). St. Louis, MO: Mosby. Chinn, P., & Kramer, M. (1999). Theory and nursing: Integrated

knowledge development (5th ed.). St. Louis, MO: Mosby. Dubin, R. (1978). Theory building. New York, NY: The Free Press. Dudley-Brown, S. (1997). The evaluation of nursing theory: A method for

our madness. International Journal of Nursing Studies, 34(1), 76–83. Fawcett, J. (1993). Analysis and evaluation of nursing theories.

Philadelphia, PA: F.A. Davis. Fawcett, J. (1994). Analysis and evaluation of nursing theories. In V.

Malinski & E. Barrett (Eds.), Martha E. Rogers: Her life and her work. Philadelphia, PA: F.A. Davis.

Fawcett, J. (2005). Criteria for evaluation of theory (Review). Nursing Science Quarterly, 18(2), 131–135.

Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-based nursing. Philadelphia, PA: F.A. Davis.

George, J. (1995). Nursing theories: The base for professional nursing practice (4th ed.). Norwalk, CT: Appleton & Lange.

Gift, A. (1997). Clarifying concepts in nursing research. New York, NY: Springer Publishing Company.

Greenwood, J. (Ed.). (2000). Nursing theory in Australia: Development and application. Sydney, Australia: Harper Collins.

Huck, S., & Cormier, W. (1996). Reading statistics & research. New York, NY: Harper Collins College Publishers.

Kim, H., Kollak, I., & Parker, M. (Eds.). (1990). Nursing theories in practice. New York, NY: National League for Nursing, Publ. #15- 2350.

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McKenna, H. (1997). Nursing models and theories. London, UK: Routledge.

McQuiston, C., & Webb, A. (Eds). (1995). Foundations of nursing theory. Thousand Oaks, CA: Sage Publications.

Nicoll, L. H. (1992). Perspectives on nursing theory. Philadelphia, PA: J. B. Lippincott.

Nolan, M., & Grant, G. (1992). Middle range theory building and the nursing theory-practice gap: A respite case study. Journal of Advanced Nursing, 17, 217–223.

Parker, M. (Ed.). (1990). Nursing theories in practice. New York, NY: National League for Nursing.

Parker, M. (Ed.). (1993). Patterns of nursing theories in practice. New York, NY: National League for Nursing, Publ. #15-2548.

Parker, M. E. (2000). Nursing theories and nursing practice. Philadelphia, PA: F.A. Davis.

Tomey, A. M., & Alligood, M. R. (Eds.). (2002). Nursing theorists and their work (5th ed.). St. Louis, MO: Mosby.

Walker, L. O., & Avant, K. C. (1997). Strategies for theory construction in nursing. New York, NY: Appleton-Century-Crofts.

Wesley, R. L. (1995). Nursing theories and models (2nd ed.). Springhouse, PA: Springhouse.

Whall, A. (1996). The structure of nursing knowledge: Analysis and evaluation of practice, middle range and grand theory. In J. Fitzpatrick & A. Whall (Eds.), Conceptual models of nursing: Analysis and application (3rd ed.). Norwalk, CT: Appleton & Lange.

Winstead-Fry, P. (Ed.). (1986). Case studies in nursing theory. New York, NY: National League for Nursing.

Young A., Taylor, S. G., & Renpenning, K. (2001). Connections: Nursing research, theory and practice. St. Louis, MO: Mosby.

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PART II Middle Range Theories: Psychological

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3 Pain: A Balance Between Analgesia and Side Effects

Marion Good

Definition of Key Terms

Analgesia Pain relief

Balance between analgesia and side effects Patient satisfaction with relief of pain and relief or absence of side effects

Identification of lack of pain or relief of side effect Pain intensity greater than the mutual goal; side effects of opioids reported by the patient or observed by the nurse

Intervention, reassessment, and reintervention Immediate intervention for pain and side effects; reassessment when peak effect is expected, and reintervention if pain and side effects are still unacceptable

Mutual goal setting Mutually agreed-upon, safe, realistic goals for relief

Nonpharmacological adjuvant Complementary nursing therapies for pain relief (relaxation, music, imagery, massage, and

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cold)

Pain An unpleasant sensory and affective experience associated with tissue damage

Patient teaching Patient instruction encouraging attitudes, expectations, and action in reporting pain; obtaining medication, preventing pain during activity, and use of complementary therapies

Pharmacological adjuvant Analgesic given as a supplement

Potent pain medication Opioid analgesic or local anesthetic given systemically or by epidural for acute pain

Regular assessment of pain and side effects Report of pain and side effects every 2 hours until under control, and then every 4 hours

Side effects Unpleasant sensory and affective experiences associated with adverse effects of pain medication

Introduction Pain is the most common reason for people to seek health care, and although pain is known to be a part of life, it is compelling in its unpleasantness and is sometimes overwhelming in its effect. Patients who are in pain endure considerable suffering and are at risk for long-term adverse effects that include slower wound healing, down-regulation of the immune system, and cancer reoccurrence (Joint Commission Resources, 2012). There are many different types of pain: acute pain of injury, surgery, labor, and sickle cell crisis; chronic pain of musculoskeletal or gastrointestinal disorders; procedural pain of lumbar puncture, venipuncture, and chest tube removal; cancer pain from the enlarging tumor, its metastases, or its treatment; and pain in infants, in the critically ill, and at the end of life. Health care professionals today have a duty and an obligation to identify the source, to treat the cause, and to relieve the pain. Theories have been developed to explain and manage pain, and researchers have an obligation to test interventions for relief.

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To study pain, researchers can experimentally induce it in animals and humans using noxious stimuli such as heat, cold, constriction, and sharpness. Or, they can study the pain of humans who are ill. In animal research, surgically exposed pain pathways provide information about the transmission of noxious impulses to the thalamus, sensory cortex, and limbic system; however, in animals, the affective component of pain is difficult to discern.

When studying humans, the patients can report both the sensory and affective components of pain, but experimentally induced pain in humans does not have the whole-person physical and emotional impact over time that clinical pain does. The pain of illness and surgery can limit life functions and arouse existential fears. The emotional impact of these limitations is intense, and it interacts with the sensory pain. Therefore, clinical studies are needed. To measure pain in alert adults who can communicate, clinicians and researchers must ask their patients to indicate a number on a scale. Further, the clinicians must believe the number that their patients tell them. Only the person in pain can tell them what his or her pain is like, and describe it in terms of its intensity, quality, duration, and the trajectory over time. Therefore, patient reports of pain are valid.

Historical Background

Theories of Pain Mechanism Beginning in the 17th century, scientists proposed various theories of the way pain events are transmitted to the brain and then felt by the person. Early pain theories included direct transmission, proposed by Descartes (Melzack & Wall, 1962), specificity theory by von Frey in 1895 (Moayedi & Davis, 2013), and pattern theories (reviewed in Melzack & Wall, 1965). Later evidence of affective pain was dramatically demonstrated by Beecher (1959), who showed that pain had a psychological component that could attenuate the transmission of impulses. The gate control theory was a major watershed or paradigm shift in pain theory (Melzack & Wall, 1965). It unified several sensory pain theories and added the affective, motivational, and central control elements, which could modify pain by descending mechanisms from the brain to the dorsal horn.

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Discoveries of endogenous opiates in the periaqueductal gray area of the brain and also opioid receptors in the central nervous system produced new scientific theories. In addition, discoveries of catecholamines, serotonin, and neuropeptide receptors produced other new theories. Scientists viewed these newer theories as either supporting or refuting the gate control theory. Some viewed them as components of a more inclusive theory. Melzack (1996) presented his new neuromatrix theory of pain that encompassed existing knowledge about the complexity of pain in humans. Melzack's theory, and the animal and patient research that it stimulated, have transformed our understanding of pain and its mechanisms (Mendell, 2014).

Nurses have created the following middle range descriptive and predictive theories of pain from the perspective of both patients and expert nurses: situation-specific theory (Im, 2006); unpleasant symptoms (Lenz, Pugh, Milligan, Gift, & Suppe, 1997); the paradox of comfort (Morse, Bottorff, & Hutchinson, 1995); a concept of pain (Mahon, 1994); concepts of acute and chronic pain (Simon, Baumann, & Nolan, 1995); nurses' perspective (Slatyer, Williams, & Michael, 2015); the journey to chronic pain (Taverner, Closs, & Briggs, 2014); and effects of chronic pain (Tsai, Tak, Moore, & Palencia, 2003). However, all of these theories describe and explain the mechanisms and manifestations of pain. They propose the way pain occurs and is modulated and its associated conditions. Although these theories are very useful, they do not specify effective interventions. Therefore, they are not the prescriptive theories needed by nurses for providing and testing interventions (Dickhoff & James, 1968).

Shift to Theories of Pain Relief A second watershed in pain theory was a paradigm shift from theories of the mechanisms of pain to theories of relief. In medicine and pharmacology, these included prescriptive and explanatory theories of opioids and of nonopioids such as local anesthetics and nonsteroidal anti- inflammatory drugs (NSAIDs). Opioids, whether taken orally or injected into blood vessels, muscles, or the epidural space, provide potent relief for moderate to severe pain. The explanatory theory (mechanism) for this effect was later found to be that opioids attach to mu and kappa opioid receptors in the central nervous system. NSAIDs, including aspirin, ibuprofen, acetaminophen, cyclooxygenase-2 (COX-2) inhibitors, and

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ketorolac, have mechanisms that are different from those of centrally acting opioids. NSAIDs act at the site of the tissue injury to decrease the release of inflammatory substances that sensitize the nerve fibers to respond to the painful stimuli. When they are used as adjuvants, NSAIDs can be opioid sparing but may also interfere with blood clotting.

Development of Integrated Prescriptive Approaches A third paradigm shift was the notion that pain alleviation by nurses requires an integrated prescriptive approach, proposed in Good and Moore's theory of a balance between analgesia and side effects (Good, 1998; Good & Moore, 1996). Integrated prescriptive pain theories specify the actions that nurses must take to deliver both medical and nursing interventions, for example, pharmacological and nonpharmacological therapies, for relief. There is an integrative pain alleviation theory for adults (Good & Moore, 1996) and also one for children that adds prescriptions for assessment of developmental level, coping strategies, and cultural background (Huth & Moore, 1998). Recent evidence-based acute pain management guidelines are consistent with the nursing theory of a balance between analgesia and side effects. Examples are guidelines published by the American Society of Anesthesiologists on Pain Management (2012), and the American Pain Society Quality of Care Task Force (2005). The principles of the Good and Moore theory have stood these tests of time and interdisciplinary agreement and are therefore current for guiding nurses when caring for patients.

Definition of Theory Concepts The major concepts of the theory, a balance between analgesia and side effects, are found in Table 3.1, along with theoretical definitions and examples of operational definitions that can be used in research. In addition, Figure 3.1 is a graphic representation of the theory. Acute pain is conceptualized as a multidimensional phenomenon that occurs after surgery or trauma and includes sensory and affective dimensions. Pain in alert adults is what the person reports. The sensory component of pain

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following damage to body tissues is the localized physical perception of hurt. It is ordinarily termed “sensation of pain.” The affective component of pain is the unpleasant emotion associated with the sensation and has been named “distress of pain” (Good, Stiller, Zauszniewski, et al., 2001), “anxiety” (Good, 1995a), or “unpleasantness” (Price, McGrath, Rafii, & Buckingham, 1983). The sensory and affective components of pain affect each other (Casey & Melzack, 1967; Johnson & Rice, 1974) and can be measured in terms of intensity magnitude.

Table 3.1 Concepts with Theoretical and Operational Definitions

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Figure 3.1 The middle range theory of a balance between analgesia and side effects prescribes nursing actions to encourage patient participation in using multimodal therapy with attentive care. (Adapted from Good, M. (1998). A middle range theory of acute pain management: Use in research. Nursing Outlook, 46(3), 120–124.)

The concept of potent pain medication refers to the major method used for relief. The potent medication may be parenteral opioids, but opioid analgesics have side effects of nausea, vomiting, drowsiness, urinary retention, and respiratory depression. In addition, dependence can also occur. To avoid these side effects, patients often take less analgesic than is needed for adequate relief (Acute Pain Management Guideline Panel, 1992). Epidural analgesia can be achieved with the use of opioids, local anesthetics, or both; these are injected into the epidural space of the spinal cord. Side effects of epidural analgesia include lower extremity numbness. Other techniques may include regional techniques such as postincisional infiltration with local anesthetics, intra-articular analgesia, and peripheral nerve blocks (American Society of Anesthesiologists Task Force on Pain Management, 2012). These methods often provide insufficient analgesia and uncomfortable side effects. Therefore, physicians often recommend adjuvants.

Pharmacological adjuvants may be given because their unrelated mechanism of action increases relief, yet can “spare” the use of strong analgesics and thus reduce their side effects. The American Society of Anesthesiologists Task Force on Pain Management (2012) reports that the

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literature suggests that two routes of administration may be more effective than one, and recommends several combinations, such as (a) epidural opioid analgesia combined with oral or systemic analgesics and (b) intravenous opioids combined with oral NSAIDs such as ibuprofen; COX- 2 inhibitors (COXIBs) such as celecoxib; or acetaminophen.

Nonpharmacological adjuvants to analgesic medication can include relaxation techniques, music, massage, cold, hypnosis, and guided imagery with self-efficacy messages, or pleasant image messages (Box 3.1). Music can be soft, soothing, sedative instrumental music (Good et al., 2000) and can be combined with relaxation or guided imagery. Nonpharmacological adjuvants have been studied during emergency treatment, following surgery and trauma, during labor, and during painful procedures.

BOX 3.1 Nonpharmacological Adjuvants

Relaxation Jaw relaxation (Good, Stanton-Hicks, Grass, et al., 1999) Autogenic phrases (Green, Green, & Norris, 1979) Progressive muscle relaxation (Pestka, Bee, & Evans, 2010) Systematic relaxation (Roykulcharoen & Good, 2004) Afrocentric relaxation exercise (Campinha-Bacote, Campinha-

Bacote, & Allbright, 1992). Slow rhythmic breathing (Park, Oh, & Kim, 2013).

Music Sedative music (Good, Albert, Anderson, et al., 2010; Good,

Stanton-Hicks, Grass, et al., 1999); Favorite music (Siedlecki & Good, 2006) Ethnomusic therapy (Campinha-Bacote, 1993; Campinha-Bacote &

Allbright, 1992).

Massage Foot massage (Ucuzal & Kanan, 2014) Massage by patient's companion (Najafi, Rast, Momennasab, et al.,

2014)

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Massage in patients with metastatic bone pain (Jane, Chen, Wilkie, et al., 2011)

Cold Gel pack during coughing after cardiac surgery (Khalkhali, Tanha,

Feizi, et al., 2014) Cold pack during labor (Shirvani & Ganji, 2014)

Guided imagery Self-efficacy imagery (Tusek, Church, Strong, Grass, & Fazeo, 1997) Pleasant imagery (Lewandowski, 2004; Locsin, 1988; Huth, Broome,

& Good, 2004) Hypnosis (Olness, 1981)

Regular pain and side effect assessments are actions nurses take to identify patient symptoms. The theory then prescribes that nurses treat these symptoms, rather than simply record them. Identification of inadequate pain relief and side effects directs the nurse to believe the patient's report of pain and to know what intensity is less than adequate relief, considering norms in the postoperative nursing unit and the wide variations in patient responses to pain and analgesics. In hospitals, nurses can request and use rescue orders and dose ranges (e.g., 1 to 2 mg), when the usual dose is insufficient (Gordon, Dahl, Phillips, et al., 2004). The nurse can also encourage the use of nonpharmacological interventions. All interventions should be followed by reassessment when the greatest effect is expected, and then reintervention if pain is still not relieved.

Patient teaching and mutual goal setting will assist patients in their important role in managing their own pain. It is proposed that nurses teach patients effective attitudes and accurate expectations of pain. Nurses also teach patients to report pain, obtain medication, and use adjuvants. It is proposed that nurses initiate dialogue for mutual goal setting to set realistic relief goals that are acceptable to their patients.

When testing a middle range theory, more specific concepts and testable hypotheses can be deducted from the more general concepts and propositions (Good, 1998). A balance between analgesia and side effects is the general outcome. To deduct more specific concepts, the researcher would think of components of the concept and state their relationships to

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the general concept. For example, the concept of side effects is a subset of the balance between analgesia and side effects. Subset concepts of sensation and distress of pain can be deducted from the concept of analgesia. In this way, sensation and distress can be studied individually (Good, 1998). Any part of the theory can be examined in research: one concept, new relationships between concepts, part of a proposition, all of a proposition, or the whole theory. In addition, the application to nursing practice or education can be studied.

Description of the Theory of Pain: A Balance Between Analgesia and Side Effects The theory of a balance between analgesia and side effects is the first integrative prescriptive middle range pain management theory. Even though it is based on pain management guidelines and is consistent with them, the theory provides a broader and more parsimonious overview. Its general principles of acute pain management are a framework for research and a guide for nursing practice and education. The theorists expect practitioners to use the overall principles, along with the detailed knowledge contained in the professional acute pain guidelines and any current empirical evidence. These overall principles can be used in practice. They are called “propositions” when referring to the theory or testing them in research. This terminology is a matter of function: principles for practice and theoretical propositions for research. Theory serves as a foundation for research and research serves as a means to test and generate theory but both serve the advancement of practice. This theory with its principles/propositions is organized to stimulate additional research and to facilitate the teaching of pain management information to nurses. Furthermore, the theory presents a new perspective that the best pain management practice is an integrated one that combines analgesic medications with nonpharmacological adjuvants, careful nursing care, and patient participation. The goal of the theory is to achieve a more holistic relief outcome than analgesia alone, that is, to balance greater pain relief with fewer side effects of opioids by using the principles.

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Scope The scope for the theory is fairly narrow, encompassing acute postoperative pain or trauma in hospitalized adults. The assumptions of the theory are presented in Box 3.2. They are fairly narrow so that prescriptions can be specific. The theorists meant the theory to be used clinically and tested in adults who have moderate to severe acute pain after surgery or trauma. The theory has limits; it does not address the treatment of pain in children, elders, or those with special kinds of acute pain. However, middle range theories have been or can be developed for these phenomena as well.

BOX 3.2 Assumptions of the Theory of a Balance Between Analgesia and Side Effects

1. The nurse and the physician collaborate to effectively manage acute pain.

2. Systemic opioid analgesics or epidural opioids or anesthetic agents are indicated.

3. Medication for side effects is given as needed. 4. Patients are adults with ability to learn, set goals, and communicate

symptoms. 5. Nurses have current knowledge of pain management.

Propositions The theory has three prescriptive propositions that can be summarized as follows: In acute pain, (1) multimodal interventions, (2) attentive care, and (3) patient participation are needed for a balance between analgesia and side effects.

The first proposition is about multimodal intervention. It proposes that nurses use potent pain medication plus pharmacological and nonpharmacological adjuvants to achieve a balance between analgesia and side effects. A multimodal effect on pain has been empirically supported. This research support was published by the Acute Pain Management

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Guideline Panel (1992) and also by Good and colleagues (Good, Albert, Anderson, et al., 2010; Good, Stanton-Hicks, Grass, et al., 1999).

The second proposition is about attentive care. It proposes that nurses assess, intervene, reassess, and reintervene to achieve a balance between analgesia and side effects. The effect on pain is supported by 30 years of research showing that pain is inadequately treated and by findings that regular assessment alone does not produce relief (Good, Auvil-Novak, & Group, 1994). Intervention, followed by reassessment after a strategic interval, and, if necessary, reintervention are needed. Reintervention can involve increasing the dose of analgesic, adding an adjuvant, or both, and reintervention should continue until a satisfactory balance is attained (Good & Moore, 1996).

The third proposition is about patient participation. It proposes that patient teaching and goal setting contribute to a balance between analgesia and side effects (see Fig. 3.1). This proposition is supported by meta- analyses for patient teaching (Devine, 1992; Devine & Cook, 1986; Lovell, Luckett, Boyle, et al., 2014; Shuldham, 1999). The idea of goal setting for pain management is supported by the expert opinion of the Acute Pain Management Guideline Panel (1992). Patient teaching is a key concept to consider when trying to improve outcomes. It should include ways to obtain medication, report pain, and use a nonpharmacological adjuvant.

Applications of the Theory The theory is useful for clinical nursing practice and also for clinical intervention research. Well-designed intervention studies are called randomized controlled trials (RCTs). The theory is useful in alert adult populations in which acute pain is incompletely controlled by medication alone, and side effects may prevent increasing analgesic medication. The theory has been adopted by postsurgical nursing units as the basis for their postoperative pain management program. It has been used many times to teach graduate nursing students the usefulness and composition of a focused, concrete nursing theory. It can also be used to teach acute pain management to undergraduate students, using the three principles (multimodal interventions, attentive care, and patient participation), along with instruction on current pain management guidelines. Valid and reliable

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assessment of pain is necessary both for research and more importantly for providing effective pain relief. A number of instruments have been developed to assess different pain experiences and pain in different populations. Table 3.2 is a sample of some of the most commonly used pain-assessment instruments.

Table 3.2 Instruments to Measure Pain

—, No abbreviation. a,b,eGood et al. (2001), b,c,d,e,f,g,r,sAcute Pain Management Guideline Panel (1992), hPrice et al. (1983), iMcCormack et al. (1988),

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s,j,kMelzack (1975), lRichards et al. (1982), mKerns, Turk, and Rudy (1985), nDaut, Cleeland, and Flanery (1983), oFishman et al. (1987), pKeele (1948), qBonnel and Boureau (1985), tBeyer, Denyes, and Villarruel (1992), uWong & Baker (1988), vMerkel, Voepel-Lewis, Shayevitz, and Malviya (1997).

Research Support for the Theory The first proposition of the theory has been partially tested. There have been many studies that have found that nonpharmacological adjuvants to analgesics were effective for acute pain. In this section, research support for the following nonpharmacological interventions will be discussed: relaxation, music, massage, and cold therapy. The third proposition has been also been partially tested: patient teaching for pain management. There have been no studies that have tested the second proposition of reassessment and reintervention and no studies that have studied the entire theory.

Relaxation Relaxation may be a way to increase patients' participation in their own pain management. An integrated review of relaxation interventions for pain showed they were effective in 8 of the 15 eligible studies. Support was found for progressive muscle relaxation, studied mainly in people with arthritis, and jaw relaxation, and systematic relaxation, both studied in postoperative pain. The reviewers concluded that more research is needed to confirm the positive findings for these three techniques (Kwekkeboom & Gretarsdottir, 2006). Two RCTs of major abdominal surgical patients showed that jaw relaxation alone (Good, Stanton-Hicks, Grass, et al., 1999) and jaw relaxation combined with soft music resulted in less pain, at both ambulation and rest, during the first 2 postoperative

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days than the control group (Good, Albert, & Anderson, et al., 2010). Jaw relaxation with music had no effect on salivary cortisol, a measure of stress (Good, Albert, Arafah, et al., 2013; Good, Stanton-Hicks, Grass, et al., 1999). Others tested jaw relaxation alone in burn patients during dressing changes, but found no effect (Rafii, Mohammadi-Fakhar, & Jamshidi Orak, 2014). Other researchers studied relaxation in patients undergoing upper abdominal surgery, to manage the increased pain from the motion of the diaphragm. The audiotaped relaxation exercise included correct breathing plus contraction and relaxation of muscle groups. Pain after upper abdominal surgery was reduced after the relaxation exercise, compared to pain scores before relaxation (Topcu & Findik, 2012). Others studied older patients after abdominal surgery and found that systematic relaxation relieved pain and reduced analgesic use during recovery from ambulation, compared to a control group (Rejeh, Heravi-Karimooi, Vaismoradi, et al., 2013).

In labor patients, reviewers found that relaxation was associated with reduction in pain intensity during the latent and active phases in three studies (Smith, Levett, Collins, et al., 2011). Although relaxation may be helpful for some labor patients, future studies should be undertaken to provide a better quality of evidence (Reis, 2012).

Benson's relaxation technique was effective with hemodialysis patients. Those randomized to the relaxation group listened to an audiotape of the technique for 20 minutes a day for 8 weeks. The relaxation group had less pain at 8 weeks (Rambod, Sharif, Pourali-Mohammadi, et al., 2014). Relaxation techniques have been shown to give patients more options and more relief than do analgesics alone.

Music Music is the most frequently studied nonpharmacological adjuvant for pain management. Six published reviews of music for pain were found: (1) a Cochrane systematic review was focused on music for postoperative pain (Cepeda, Carr, Lau, et al., 2006); (2) a systematic review of music for pain in hospitalized patients (Cole & LoBiondo-Wood, 2014); (3) a systematic review of music for pain in critically ill patients (Chlan & Halm, 2013); (4) a review of music for acute, chronic, and cancer pain (Huang & Good, 2013) and two reviews of music for cancer pain; (5) a Cochrane review (Bradt, Dileo, Grocke, & Magill, 2011); and (6) a meta-analysis (Tsai, Chen, Chung, et al., 2014).The largest individual study was by Good,

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Albert, Anderson, et al. (2010); music combined with relaxation was effective for postoperative pain in three of five instances in 517 abdominal surgical patients. Although, music is not effective at all times or for all patients. The evidence published in many individual studies and in a variety of medical and surgical conditions, the reviewers concluded that on average, music reduced pain—and the size of the reduction was usually small to medium.

Music is available, safe, inexpensive, and acceptable to many patients; does not add side effects; and in most cases improves patient satisfaction (Gelinas, Arbour, Michaud, et al., 2013). Music should not be used in place of analgesic medication, but adds relief when used along with it. Nevertheless, the many studies supporting the effectiveness of music for pain can only partly inform nurses about whether individual patients should try it (Holden & Holden, 2013). The nurse should always ask patients first whether they would like to try listening to some music for distraction or relaxation along with their pain medication (Chlan & Halm, 2013). Music selections chosen by the patient are often best, because people are more likely to listen to and respond to something they like. On the other hand, some people do not care for music and some do not want to listen to music when they are ill. Some may want to listen to music for other reasons than pain. The reasons offered by people with chronic pain were to gain control over pain; to relieve tension, anxiety, boredom, and loneliness; and to engender thankfulness (Holden & Holden, 2013). For patients who wish to listen to music, nurses should accept that music affects pain and persons differently and that some patients have good relief during the time they are listening to music and some have only a little relief.

Massage Studies of the use of massage for pain have provided initial support for the nonpharmacological part of the first proposition. Following early small studies that suggested that massage therapy could relieve pain, researchers conducted a multisite RCT with patients having advanced cancer. Massage resulted in less pain and better mood in the immediate term (Kutner, Smith, Corbin, et al., 2008). A later RCT of patients with metastatic bone pain showed that massage resulted in a significant reduction in pain and that the effects on relaxation were sustained for hours (Jane, Chen, Wilkie, et al., 2011). In patients who have had coronary artery bypass graft

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surgery, massage therapy was given by the patient's companion, who was trained by a nurse. In the massage group, pain intensity decreased at all four time points after the intervention, while it did not in the control group (Najafi, Rast, Momennasab, et al., 2014). In two other studies, massage also had positive results on pain. Foot massage along with analgesic medication provided pain relief immediately after breast surgery, compared to those who received analgesics alone (Ucuzal & Kanan, 2014). In a Veterans Administration hospital, those who received massage as part of their care had pain decreases in the immediate term (Mitchinson, Fletcher, Kim, et al., 2014).

Massage therapy is increasingly offered to hospitalized patients for pain and other symptoms. A decade of massage therapy services at a large tertiary medical center was summarized to show the way it developed from early pilot studies to the current program (Rodgers, Cutshall, Dion, et al., 2014). However, although patient risk in massage therapies is low, this intervention is not completely without risk (Yin, Gao, Wu, et al., 2014). There are a variety of types of massage; the clinician is advised to consider the patient's condition and the potential risk and to also be familiar with the technique, preferably in collaboration with a massage therapist.

Cold Cold therapy is the oldest analgesic that is still being used clinically. Studies of the use of cold provided initial partial support for the first proposition. Since the advent of easy-to-use cold packs, recent studies have tested the use of cold in innovative ways. One group of researchers found that a cold gel pack reduced the pain associated with coughing and deep breathing following cardiac surgery (Khalkhali, Tanha, Feizi, et al., 2014). Other researchers found that during chest tube removal, using three gel packs wrapped in gauze around the wound for 10 minutes prior to the procedure reduced pain that was measured afterward (Gorji, Nesami, Ayyasi, et al., 2014). Third, in labor patients, cold packs were applied over the abdomen and back for 10 minutes every half hour during the first phase of labor. Cold packs were also applied over the perineum for 5 minutes every 15 minutes during the second phase. They found that pain was less in the group that received cold therapy during all parts of active phase and the second stage. In addition, the duration of all phases of labor was shorter in the cold therapy group (Shirvani & Ganji, 2014). A fourth group of researchers found that during tonsillectomy, the intraoperative

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cooling of the excised area with cold saline reduced postoperative pain during the first 10 days (Shin, Byun, Baek, et al., 2014). Principles, techniques, and nursing care involved in cold therapy can be found in McDowell, McFarland, and Nalli (1994). Box 3.3 provides a summary of some of the research that has tested the effectiveness of nonpharmacological adjuvants on the pain experience.

BOX 3.3 Examples of Nonpharmacologic Adjuvants Used in Practice

Nurses' use of relaxation for postoperative pain, which includes general instructions and specific relaxation techniques is described in Good (1995b). The empirically tested jaw relaxation technique is included, because it is easy for patients to remember after surgery. When recorded on an audiotape, soft relaxing music could be added. More recently, nurses' use of relaxation for pain management in nursing practice was carefully described by Schaffer and Yucha (2004). They provide a sample of a full body relaxation script that nurses can read to patients or record on an audiotape for the patient to use independently. They also review the empirical literature that supports the use of relaxation techniques for pain and provide two clinical case studies that illustrate the use of relaxation for neck, back, and headache pain.

Nurses' use of soft music to ease the pain of clinical patients is based on nursing studies in postoperative patients, and in patients with the pain of labor, osteoarthritis, cancer, and chronic pain. Based on Nightingale's framework, McCaffrey (2008) discussed nurses' use of music as a healing environment for older adults having surgical, arthritis, and other kinds of pain. She recommends that nurses be given educational sessions to understand the use of music as an intervention in various settings. She encourages assessing preferences, offering a variety of types of music for patients to choose from, use of iPods®with downloaded music, bringing music from home, and she lists some composers and CDs that have been used in her studies. Others describe the use of music for labor pain, recommending that women be advised during prenatal childbirth classes of the efficacy of music for pain and relaxation (Zwelling, Johnson, & Allen, 2006). Music should be chosen and obtained in advance, and women should bring their own playing equipment, if it is not available in the hospital. Zwelling et al. (2006) give recommendations for use of

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complementary therapies in general, including educating the labor and delivery nurses in their use.

The third principle of the theory is that patient teaching and goal setting contribute to balance between analgesia and side effects. Nurses at the bedside can use current guidelines to teach patients to manage pain pharmacologically (McCaffery & Pasero, 1999). An example of a patient and family information sheet for patient-controlled analgesia (PCA) can be found at http://www.greenhosp.org/pe_pdf/pain_PCA.pdf. Setting goals with patients is described in detail by Pasero and McCaffrey (2003, 2004). Teaching patients to use a pain rating scale is the first step, and the next step is establishing a comfort-function goal. Examples of comfort-function goals for postoperative patients are given in Pasero and McCaffrey (2003). The goal should be documented on the chart, close to the pain scores; if the goal is not met, the pain rating should be addressed with interventions to relieve it. Nurses should consider whether an analgesic can be given, or whether to use the range of doses ordered by the physician, call the physician for further orders, and/or add a nonpharmacological therapy. The nurses should then reassess pain and side effects at a time when they are expected to be effective and reintervene if necessary. The health care team's achievement of the comfort-function goals should be monitored in quality improvement plans. Nurses can help patients establish realistic comfort-function goals and should discuss them during shift report and rounds. Pasero and McCaffrey (2004) emphasize that pain assessment does not necessarily mean pain relief.

Extension of the Theory The portion of the theory regarding the effect of nonpharmacological interventions on pain has been extended to other populations, because of research support. For example, music has reduced chronic pain (Siedlecki & Good, 2006), labor pain (Phumdoung & Good, 2003), arthritis pain (McCaffrey & Freeman, 2003), pain of bone marrow aspiration (Shabanloei et al., 2010), pain of burn dressing changes (Tan, Yowler, Super, et al., 2010) and cancer pain (Chiang, 2011; Huang, Good, & Zausniewski, 2010). Also, guided imagery has reduced chronic pain (Lewandowski, 2004), and back massage reduced back pain after abdominal surgery in Asian patients who remain on bed rest after surgery

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http://www.greenhosp.org/pe_pdf/pain_PCA.pdf

but had no effect on incisional pain (Chin, 1999).

Patient Teaching Studies of patient teaching specifically for acute pain management have shown very little support for that part of the third proposition. Patient teaching for pain management after surgery potentially informs and empowers patients by increasing their knowledge and self-efficacy for engaging in postoperative care activities and using their PCA. However, in two older studies, brief interventions for PCA use had no effect on pain, whether delivered by pamphlet (Chumbley, Ward, Hal, et al., 2004) or anesthetists' teaching and demonstration (Lam, Chan, Chen, et al., 2001). A recent study also found no effect for video education for pain management in patients undergoing colorectal resection (Ihedioha, Vaughan, Mastermann, et al., 2013). Our RCT also found that a 5-minute audiotaped teaching intervention for pain management had no effect on pain after abdominal surgery (Good, Albert, Anderson, et al., 2010). It taught patients to let go of fears of opioid dependency, to use their PCA system, and to tell their nurse about their pain until relief was obtained. Another group of researchers added preemptive analgesia to preoperative teaching for thoracotomy patients, and they did find improvements in pain and analgesia intake. However, it is not clear whether the result was due to the preemptive analgesia rather than the patient teaching (Kol, Alpar, & Erdogen, 2014). Each of these investigators used different teaching methods and content. Thus, an effective teaching intervention for patient involvement in their acute pain management has not yet been tested. However, a meta-analysis of patient education for cancer pain may provide some direction for teaching patients with acute pain. Optimal strategies included strategies that were patient centered and tailored to individual needs, as part of therapeutic relationships (Lovell, Luckett, Boyle, et al., 2014), in contrast to pamphlets, audiotapes, and videotapes used in acute pain studies.

Suggestions for Additional Research The time has come to conduct studies that translate the use of some of these interventions to nursing practice. Studies are particularly needed for postoperative pain, chronic pain, and pain of labor osteoarthritis, and

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cancer. Studies of massage, cold, and patient teaching need further development and testing.

Relaxation More studies of jaw relaxation and systematic relaxation are needed following surgery. They need to continue to be tested in various age groups and surgeries and in various countries and cultures, both at ambulation and rest. The whole-body systematic relaxation technique described in Roykulcharoen and Good (2004) should be tested in a replication study and then compared after surgery to jaw relaxation (Good, Stanton-Hicks, Grass et al., 1999). More research on relaxation is needed in laboring patients to confirm the studies reported here.

Culturally congruent relaxation scripts and voices can be developed and used in practice and research. An excellent example can be obtained from Dr. Josepha Campinha-Bacote, a Cape Verdean transcultural nurse who is an expert on ethnomusic therapy and culturally competent nursing care. She, an African–American jazz musician, and her husband developed a tape entitled “Culturally Specific Africentric Relaxation Exercise,” which is accompanied by music that is congruent with the African– American culture. Nurses could develop such tapes for other cultural and ethnic groups by incorporating principles of ethnomusicology and music therapy.

Music Music should continue to be tested and replicated in various painful conditions, such as chronic pain, cancer pain, and procedural pain. Choices of music that are culturally and age appropriate should be offered. Individual studies should be developed in other countries. This work has begun with my doctoral graduates who have developed Korean (Good & Ahn, 2008) and Taiwanese music tapes (Chiang, 2011; Huang et al., 2010) to appeal to patients in those countries. Studies are needed to compare slow, sedative music for pain with music with faster tempos. Studies are also needed to compare the effects of different musical instruments or to compare music with lyrics to music without lyrics; these may be influenced by the culture of the participants. Cultural preferences in music for pain need to be studied in the many countries and cultures in the world.

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Practicing nurses need to become aware of the cultural preferences in their patient populations.

Massage There needs to be replication of the initial massage studies for acute pain that were reported earlier in this chapter. In addition, qualitative studies are needed to describe variations in patient reaction to massage. Studies of hand and foot massage for pain in other parts of the body are needed. Various types of massage that are appropriate for a patient condition can be compared for their effectiveness and acceptability to patients. See Harris (2014) for descriptions of types of massage.

Cold Replication is needed to support the findings of the studies reported earlier in this chapter. In addition, new ways of using cold can be developed and tested. The new ways would need to be appropriate to the patient condition and should be used in accord with institutional procedures for the use of cold.

Attentive Care Attentive care could be studied by using a record review. Researchers can track the actions of nurses who are required to record pain care that includes intervention, reassessment, and reintervention until relief is obtained. Data collection would also include the use of range doses and adjuvant nonpharmacological methods of pain relief and calling the doctor if necessary. This research would describe the extent to which the second proposition is used in practice.

Patient Teaching and Goal Setting New methods of patient teaching for use of PCA for postoperative pain need to be developed. The most promising teaching interventions should be tested in research. Setting comfort-function goals could be compared to usual care. Comfort-function goals are discussed by Pasero and McCaffery

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(2004). Methods of teaching patients to use nonpharmacological methods to use as adjuvants also need testing. Researchers can use the pain scales listed in Table 3.2. In addition, Box 3.4, Using Middle Range Theory in Research, provides an example of a study designed to further test the theory.

USING MIDDLE RANGE THEORY IN RESEARCH 3.4

Source: Sng, Q. W., Taylor, B., Liam, J. L. W., Klainin-Yobas, P., Wang, W., & He, H. (2013). Postoperative pain management experiences among school-aged children: A qualitative study. Journal of Clinical Nursing, 22, 958–968. doi: 10.1111/jocn.12052.

Purpose/Research Question The purpose of the study was to explore the postoperative pain

experience of school-aged children.

Research Design Qualitative (phenomenological)

Sample/Participants Fifteen children, ages 6 to 12 years old, admitted to pediatric

surgical units in a tertiary, public hospital in Singapore. For inclusion, the child's surgery needed to require a minimum of more than 24-hour postoperative hospitalization. They also needed to be considered stable postoperatively.

Data Collection The children were interviewed using a semistructured format, using

a guide based on previous research. Each interview took approximately 10 minutes and was audiotaped.

Findings Four themes emerged:

1. Children's self-directed actions to relieve pain postoperatively: (a)

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cognitive behavioral methods, for example, distraction; (b) physical methods, for example, positioning; (c) seeking help from others, for example, informing parents; and (d) pain medication

2. Children's perceptions of parents' actions to relieve their pain: (a) assessing their pain; (b) giving pain medication; (c) using cognitive behavioral methods, for example, distraction; (d) using physical methods, for example, massage; and (e) using emotional support strategies, for example, reassuring words and touch

3. Children's perceptions of nurses' actions to relieve their pain: (a) administering medication; (b) using cognitive behavioral methods, for example, distraction; (c) using emotional support strategies, for example, reassurance; and (d) helping with activities of daily living

4. Suggestions for parents for alleviating postoperative pain: (a) using distraction and (b) being present

5. Suggestions for nurses for alleviating postoperative pain: (a) administering medication, (b) using distraction, and positioning

The researchers concluded that “it is important for health care professionals to value children's roles in their postoperative pain management” (p. 966).

Use of the Theory in Practice Nurses have written to the author saying that they use the theory as a basis of practice on their postoperative unit. However, examples of use of the entire theory were not found in the literature. There are articles that describe how nurses use parts of the theory, that is, complementary therapies in addition to analgesics, and patient teaching and goal setting for pain relief. An excellent resource is Complementary & Alternative Therapies in Nursing by Lindquist, Snyder, and Tracy (2014). For an example of use of the theory, see Box 3.5, Using Middle Range Theory in Practice, which provides a detailed description of a specific adjuvant used in practice to promote pain relief.

USING MIDDLE RANGE THEORY IN

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PRACTICE 3.5

Source: Schaffer, S. D., & Yucha, C. B. (2004). Relaxation and pain management. American Journal of Nursing, 104(8), 75–82.

Problem Analgesics have not consistently provided adequate relief of acute

and chronic moderate-to-severe pain nor to related symptoms, such as restlessness, irritability, muscle tension, difficulty concentrating, and sleep problems.

Nursing Intervention Relaxation can be taught as an adjuvant to the administration of

analgesics. Before teaching a relaxation technique, nurses assess the patient and establish rapport. Teaching is most effective with those patients in mild-to-moderate pain who have already used nonpharmacological methods and are interested and able to learn a new skill. It should be explained that relaxation is not a substitute for analgesic medications but just a means of enhancing them.

Patients should wear loose, comfortable clothing, be in a comfortable bodily position, and be in a comfortable environment with privacy, dim lighting, and the absence of distractions. The relaxation technique chosen should take into consideration patient preference, provider competency, and relevant contraindications of the method.

Give directions calmly and slowly, using short sentences. Begin by having the patient assume a relaxed body position with body in alignment, properly supported with eyes closed and mouth relaxed and slightly opened. Proceed to teach either breathing techniques or muscle relaxation techniques as a means of promoting relaxation. The techniques can be taught in as little as 15 minutes. For optimal results, the patient should practice the relaxation techniques for 10 minutes twice daily.

It would be ideal if an entire postoperative nursing unit would implement the complete theory in caring for their patients. They could first assign readings from this chapter and then hold educational sessions for the nursing staff on pain management, the theory, and the advantages of using

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evidence-based theories and interventions. In these sessions, nurses could discuss the concepts of the theory and learn what could be offered in terms of analgesics (American Pain Society, 2008) and range orders (Gordon, Dahl, Phillips, et al., 2004), nonpharmacological adjuvants, patient teaching, and goal setting. They could discuss the day-to-day relief goals and comfort-function goals that they think would be realistic on their unit as patients recover. They could discuss the meaning of attentive care (e.g., intervention, reassessment, and reintervention, until a comfort-function goal is met) (Pasero & McCaffery, 2003, 2004). Since Good, Albert, Anderson, et al. (2010) found that an audiotaped patient teaching for pain management intervention was not effective for pain reduction, nurses on the unit should employ patient-centered strategies that are tailored to individual needs and are part of a therapeutic relationship to teach patients to use their PCA effectively (Lovell, Luckett, Boyle, et al., 2014; McCaffery & Pasero, 1999).

To use relaxation or music clinically, nurses would need to secure a small amount of funding to provide a modest library on the unit containing relaxation exercises, music, and guided imagery on audiotapes, compact discs, or iPods. It is important to use equipment for playing that could be easily used by the patients. Practice information on using a relaxation intervention can be found in Good (1995b), and information on using a music intervention for pain can be found in Good, Picot, Salem, et al. (2000). Practitioners can use the Numeric Pain Intensity Scale (Table 3.2) to measure pain regularly in adults and any of the children's pain scales that are age appropriate.

Using massage in nursing practice requires knowledge of the patient's condition and avoidance of massaging areas of the body that are likely to be harmed by pressure and motion on the skin. Precautions are discussed in Harris (2014, pp. 263–264). Precautions taken in research with patients following breast surgery can be found in the inclusion and exclusion criteria and the data collection sections in the study by Ucuzal and Kanan (2014) on page 260. These nurse researchers also consulted a massage therapist to train them in the technique. In nursing practice, consultation with a massage therapist is recommended until nurses on the unit learn the technique and become proficient.

Using cold therapies in nursing practice also requires knowledge of the patient's condition and collaboration with the physician to determine appropriate use. Cold packs are sometimes ordered following some surgeries. For example, following a herniorrhaphy, dental surgery, or a

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fracture, a cold pack may be ordered for a day or 2 to reduce swelling and pain in the operative site. It is important to use the cold pack in an intermittent manner, so that the tissues do not become too cold. In Table 3.3 there are examples of research evidence to support the use of the theory in the relief of pain.

Table 3.3 Examples of Research for Application to Practice

Using attentive care and intervening until pain is relieved has been incorporated into practice better today than 19 years ago when the theory was first published. Today, there is greater attention to pain relief in the United States, due to increased research and improved requirements of the Joint Commission. Nevertheless, nurse educators must continue to teach this principle to students. Nursing educators and administrators in hospitals in which attentive care for pain is not practiced may want to provide some in-service education on pain management and study whether nurses improve in knowledge and in their practice with patients in pain.

Summary

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Pain is a universal human experience that has been known since the first human experienced illness, trauma, or labor. Although pain has been studied descriptively for more than a century, it has only recently been studied from a prescriptive nursing perspective. The middle range prescriptive pain management theory of a balance between analgesic and side effects reflects the nursing mission to intervene effectively and holistically to relieve pain and suffering and to prevent their long-term effects. There is increasing empirical support, and nurse researchers can continue to test and to provide support and creative extensions of the theory. Practicing nurses are using the evidence-based principles for effective relief of acute pain in their patients.

Critical Thinking Exercises

1. Compare two scenarios or scripts for nurses and patients engaging in mutual goal setting for pain management after a specific surgical procedure. With peers, analyze each for advantages and disadvantages to the patient and to those who provide care.

2. Analyze the trajectory of patients undergoing a specific surgical procedure and the places they receive nursing care, from the surgeon's office and the decision for surgery, through the pre- and postoperative hospitalization, to recovery at home. Plan the most effective times, amounts of information, and ways nurses can introduce and reinforce the elements of patient teaching for pain management. The elements are to encourage attitudes, expectations, and actions in reporting pain, obtaining medication, preventing pain during activity, and using complementary therapies. Describe ways by which this nursing care, delivered in several places, could be streamlined and coordinated with the surgeon's patient teaching.

3. Envision yourself as a leader who is introducing this nursing theory as the basis of postoperative pain management on your unit. Create introductory scripts with arguments for its usefulness to be delivered to the nursing and medical staff. Describe how you would begin to demonstrate its usefulness. Explain your method of presenting its current evidence base. Give the main points of a clinically useable protocol for your unit.

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Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Pain: A Balance Between Analgesia and Side Effects.

Acknowledgments This chapter was supported in part by the National Institute of Nursing Research (NINR) Grant Number R01 NR3933 (1994–2005), to M. Good, PhD, Principal Investigator, and by the General Clinical Research Center, Case Western Reserve University.

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4 Unpleasant Symptoms

Elizabeth R. Lenz, Linda C. Pugh, Renee Milligan, Audrey Gift

Definition of Key Terms

Performance Performance is the multifaceted outcome or result of the symptom experience. It includes physical, functional, and cognitive activities. Functional performance includes activities of daily living (ADLs), social interaction, and role performance. Cognitive performance includes knowledge and ability to learn, remember, solve problems, and think abstractly and logically. Quality of life (QoL) can be considered an indicator of performance, because it incorporates both functional ability and cognitive ability as perceived by the individual experiencing the symptom(s).

Physiological factors Physiological factors are the normal or abnormal functioning of bodily systems. They may include diseases and dysfunctions, treatments and medications taken in the past or currently, physiological and anatomical abnormalities, comorbidities, diet and nutritional balance, hydration, and amount of exercise. They include the age and gender of the individual.

Psychological factors Psychological factors include mental state or mood, affective reaction to illness, and the degree of uncertainty and knowledge about the symptoms and their meaning to

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the individual.

Situational factors Situational factors include aspects of the social and physical environment that surround the person and may influence the experience, interpretation, and reporting of symptoms. They include environmental factors, such as heat, humidity, noise, light, safety, and air and water quality. They may include socioeconomic factors, marital status, and social support.

Unpleasant symptoms Symptoms are the perceived indicators of change in normal functioning as experienced by patients. They are the subjective indicators of changes in and threats to health. Generally, they are experienced as unpleasant sensations.

Introduction The theory of unpleasant symptoms (TOUS) is a middle range nursing theory that was developed and intended for application and use by nurses and clinical researchers. The original concept paper appeared in 1995 and was revised in 1997. The theory allows for the presence of multiple symptoms that interact and/or are multiplicative. It implies that experience and management of one symptom will contribute to the experience and management of others.

Historical Background In 1993, two efforts that emerged from clinical practice and empirical research led to the development of the TOUS. Linda Pugh and Audrey Gift, clinical researchers each studying a single symptom (fatigue and dyspnea, respectively), developed a model that included elements believed to be common to both symptoms. Pugh's practice and research specialty was intrapartum fatigue. She teamed with Renee Milligan whose practice and research specialty was postpartum fatigue. Together, they developed a framework for childbearing fatigue that identified common factors related to fatigue across the childbearing period. Both the model and the

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framework linked antecedent or influencing factors to the symptom of interest and the way in which it is reported by patients. In addition, the symptom was conceptualized as an experience that influences performance outcomes. In addition to noting that the models for the two symptoms were similar, Gift and Pugh realized that similar interventions, such as the use of progressive muscle relaxation, had been proposed and tested for both dyspnea and fatigue. These management techniques were consistent with those proposed for the management of pain.

Both symptom models were usable, but there was a need for a more abstract and inclusive model that could encompass these and other symptoms. Elizabeth Lenz, who was familiar with the work of all three researchers, took the lead to call the collaborators together to further develop the more inclusive model. The team was joined by Frederick Suppe, an eminent philosopher of science with a wealth of experience related to scientific theory and nursing science. The authors began meeting regularly to develop the model, assign writing tasks, and discuss each other's work. The more abstract model that resulted was presented to the nursing scholarly community as an exemplar of a middle range nursing theory (Lenz, Suppe, Gift, Pugh, & Milligan, 1995).

In a later revision and amplification of the TOUS, the authors refined the model to be more realistic, that is, more accurately to reflect the complexity and dynamism of clinical situations (Lenz, Pugh, Milligan, Gift, & Suppe, 1997). The multiplicative nature of symptoms, the interaction among the influencing factors, and the feedback among the factors, symptoms, and performance were integrated into the theory.

The Theory of Unpleasant Symptoms Many models of symptoms focus on one symptom and specifically on its severity or intensity, not on other features, such as quality, distress, or duration. The TOUS was one of the earliest to portray multiple symptoms occurring together and relating to each other in an additive or multiplicative manner, potentially catalyzing each other. Thus, this theory, which allows for the presence of multiple symptoms and implies that management of one symptom will contribute to the management of others, is consistent with the large body of current literature that addresses symptom clusters, which are multiple symptoms that occur simultaneously

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and are related to one another (Dirksen, Belyea, & Epstein, 2009; Jurgens et al., 2009; Motl & McAuley, 2009; Motl, McAuley, & Sandroff, 2013; Roiland & Hendrich, 2011; So et al., 2009; Wang & Fu, 2014).

Description of the Theory of Unpleasant Symptoms The TOUS addresses the symptom experience and allows a focus on either multiple symptoms occurring together or a single symptom. It has been used as the theoretical framework to guide several studies of the symptom experience associated with a variety of illnesses, including cancer, chronic obstructive pulmonary disease, heart failure, gastric and transplant surgery, multiple sclerosis, and Parkinson's disease. It also has been used as the framework for studies involving the elderly, and women experiencing intimate partner violence, pregnancy, and the postpartum period (e.g., Cho et al., 2012; Chen, Li, Shieh, Yin, & Chiou, 2010; Dirksen, Belyea, & Epstein, 2009; Jurgens et al., 2009; Robinson et al., 2013; Rychnovsky, 2007; Woods, Kozachik, & Hall, 2010). The symptoms are viewed as having either a multiplicative or an additive relationship to one another. Symptoms have antecedent factors that are categorized as physiological, psychological, and situational (environmental). These antecedents are interactive and reciprocal as they relate to one another and to the symptom(s) (Fig. 4.1).

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Figure 4.1 Theory of unpleasant symptoms. (From Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14–27. Copyright 1997 by Lippincott Williams & Wilkins.)

Symptoms have the measurable dimensions of intensity (severity), timing (frequency, duration, trajectory pattern, and relationship of onset to precipitating events), distress (the person's reaction to the sensation, which is influenced by the meaning the person assigns to it), and quality (descriptors used to characterize the way the symptom feels and/or its location). The quality dimension may be difficult to measure, depending on the culture and language of the patient and the number of symptoms experienced at the same time. The dimensions can vary independently but often relate to one another (e.g., Kim, Malone, & Barsevick, 2014; Matthie & McMillan, 2014; McMillan, Tofthagen, Small, Karver, & Craig, 2013).

The antecedent factors are categorized as physiological, psychological, or situational. Physiological antecedents may include the individual's age,

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gender, precipitating illness(es) or dysfunction(s), or normal developmental stage (e.g., menopause). Additional physiological antecedents can be an event (e.g., pregnancy), comorbidities, abnormal blood values, or any other physiological findings that can be attributed to the illness or its treatment (e.g., medication, surgery, or radiation therapy). Psychological factors affecting the symptom experience may include the person's mood or emotional state, affective reaction to disease, degree of perceived uncertainty regarding the symptoms or the illness, level of perceived self-efficacy, and the meaning ascribed to the symptoms by the patient. Situational factors refer to aspects of the social and physical environment that may affect individuals' symptom experiences and their reporting of those experiences. Examples include the physical nature of the immediate environment (e.g., noise, temperature) and multiple aspects of the social environment (e.g., social support, marital status, cultural background, socioeconomic status, occupation, family and work demands, relationships with care providers, and available resources). Generally, situational factors are external to the individual.

In the TOUS, symptoms are hypothesized to affect performance, which includes functional and cognitive domains. Functional performance refers to an individual's ability to perform physical activity, including activities of daily living (ADLs), self-management, care seeking, and carrying out social and personal roles. Cognitive performance is the ability to concentrate, remember, learn, solve problems, reason, and/or think. There is empirical support for relationships between patterns of cognition and levels of symptoms experienced (e.g., Hsiao, Moore, Insel, & Merkle, 2014; Kim et al., 2014).

In the most recent version of the theory (Lenz et al., 1997), multiple symptoms are conceptualized as potentially occurring simultaneously and interacting with one another, as are antecedent factors (see Fig. 4.1 for a model of the TOUS). Interactive and reciprocal relationships among the antecedent factors and symptoms are also hypothesized. Symptoms are hypothesized to influence performance. Performance, likewise, reciprocally affects the symptom experience and may also change the antecedent factors. See Using Middle Range Theory in Research 4.1, Using Middle Range Theory in Practice 4.2, and Table 4.1 Examples of Research for Application to Practice for examples of the use of the theory.

Table 4.1 Examples of Research for Application to Practice

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USING MIDDLE RANGE THEORY IN RESEARCH 4.1

The TOUS has provided the framework for clinical research projects examining a wide variety of populations and settings. In a recent example, Eckhardt, DeVon, Piano, Ryan, and Zerwic (2014) used the TOUS to guide a mixed method study of fatigue in patients with stable coronary heart disease.

Research Design This study used a mixed method approach.

Sample/Participants A variety of populations and settings were included in this study. A

cross section of 102 patients with stable CHD and who met the inclusion and exclusion criteria from two cardiology units was enrolled after signing the informed consent that was approved by the hospital's IRB. These patients participated in several quantitative research

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methods. An additional 13 patients from the same cardiac units were chosen to participate in qualitative reviews. One hospital was considered urban, while the other hospital was rural.

Data Collection Data was collected using a variety of tools. Quantitative instruments

were The Fatigue Symptom Inventory, the Patient Health Questionnaire-9, and the SF-36. Qualitative interviews of patients were also conducted.

TOUS elements included four dimensions of fatigue (distress, timing, quality, intensity); situational (age*, sex*, education, income), psychological (depressed mood), and physiological (comorbid conditions, hypertension, diabetes, medications) factors; and performance (quality of life, functional status).

Findings A majority of participants reported “clinically meaningful” fatigue

more than 3 days/week; women reported higher levels of interference with activities than men.

Consistent with the TOUS, depressed mood predicted the intensity and interference level of fatigue, and quality of life was influenced by fatigue. The qualitative findings validated the quantitative results adding to the strength and validity of this study.

*In the TOUS, these variables are categorized as physiological factors.

USING MIDDLE RANGE THEORY IN PRACTICE 4.2

Source: Johnson D., & Roberson, A. (2014). The evaluation of the effectiveness of relaxation training and sleep hygiene education for insomnia of depressed patients. Clinical Scholars Review, 6, 39–46. http://dx.doi.org/10.1891/1939-2095.6.1.39

Problem

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http://dx.doi.org/10.1891/1939-2095.6.1.39

In a recent project that examined practice evidence, Johnson and Roberson (2013) used the TOUS to evaluate two common nonpharmacologic psychiatric nursing clinical interventions (relaxation training and sleep hygiene education) for treatment of insomnia in ten depressed patients clinically managed pharmacologically.

Nursing Intervention The TOUS is increasingly being used as a basis for designing

interventions aimed at improving symptom experiences in a variety of situations, such as

Care of postoperative patients and those with chronic illnesses (Bekelman et al., 2014; Tyler & Pugh, 2009) Caring for cancer survivors during and following chemotherapy (Hsiao et al., 2014; Matthie & McMillan, 2014) Postdelivery care of inner-city mothers and encouragement to prolong breast-feeding (Pugh & Milligan, 1998; Pugh, Milligan, Parks, Lenz, & Kitzman, 1999) Encouraging patients to self-manage their symptoms (Hoffman, 2013)

Insomnia and depressed mood were the unpleasant symptoms, and the TOUS symptom characteristics were timing, distress, intensity, and quality. Further, the project embodied the notion of symptom interaction.

Findings Conclusions shaped by this comprehensive approach were that

evidence-based practice interventions of sleep hygiene education and relaxation training complemented pharmacologic management of symptoms in depressed patients.

Models That Expand or Modify the Theory of Unpleasant Symptoms Brant, Beck, and Miaskowski (2010) conducted a systematic review of

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models related to symptoms or symptoms management. The two seminal models they identified were the TOUS and the Theory of Symptom Management (TSM; Humphreys et al., 2014), an outgrowth of the Symptom Management Model (SMM; University of California, San Francisco Symptom Management Faculty Group, 1994). Models that have expanded or modified the TOUS include the Symptoms Experience Model (SEM) by Armstrong (2003); the Symptoms Experience in Time Model (SET) by Henly, Kallas, Klatt, and Swenson (2003); and the Theory of Symptom Self-Management (TSSM) by Hoffman (2013). In addition to the models that have been developed to expand the TOUS, a number of investigators have tested aspects of the theory and, based on their findings, have suggested modifications (see Lenz & Pugh, 2014). It has also been used as a basis for investigator-generated models, which are then tested using path analytic and structural equation modeling techniques (e.g., Hoffman et al., 2009; Hsu & Tu, 2013; Kapella, Larson, Patel, Covey, & Berry, 2006; So et al., 2013). These techniques have substantiated the importance of including the potential for mediating effects in the TOUS.

Armstrong's Symptom Experience Model Armstrong (2003) proposed a symptom model that builds on the TOUS but focuses attention on the meaning or perception of the symptom as well as its expression. Multiple co-occurring symptoms can interact and affect the patient's perception of the symptom as a new or recurring event and his or her perception of the ability to deal with the situation. Armstrong further extends the TOUS to include the existential meaning of the symptom(s) to the patient, either negative or positive. In Armstrong's modification, antecedents are reorganized as demographic, disease, and individual characteristics. Symptom dimensions are frequency, intensity, and distress (consistent with the TOUS) and the descriptor of symptom meaning. In the TOUS, the assumption is that the individual's interpretation of the symptom's meaning is captured in the level of distress. In the SEM, the consequences of the symptom experience are expanded beyond physical, social, and role performance (and cognitive functioning) to include emotional consequences. Armstrong's model is appropriate to use when the meaning or emotional consequences of the symptom is the focus of the investigation or intervention.

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Symptom Experience in Time Model The SET model was conceptualized by combining the TOUS and the SMM (now the TSM) with a time model for the purpose of examining symptom flow (Henly et al., 2003). In this model, the symptom is initiated by a precipitating event that leads to its onset. The influencing factors of the TOUS are broadened to include nursing metaparadigm concepts of person, health, and environment that mediate or moderate the symptom. Every symptom has an onset, an experience, a cognitive evaluation, and an emotional response. The symptom dimensions are retained from the TOUS. The cognitive evaluation determines whether the symptom is serious, unpleasant, and/or inexplicable. Each symptom is also evaluated as being chronic or treatable. If treatable, symptom management can take the form of either self-care or help-seeking behavior. The outcomes of these strategies can be changes in the symptom itself, as well as changes in the person, his or her health, and/or the environment.

Time, a factor determining the patterning of a symptom experience, may serve as input to the symptom experience, or as output from the symptom management process (Henly et al., 2003). It may also be a component of an intervention. Time has different patterns whether considering perceived time, biological/social time, or clock/calendar time. The SET model provides a helpful conceptual amplification of time as an important dimension of the symptom experience.

Theory of Symptom Self-Management The TSSM builds upon the TOUS with the aim of improving clinical practice (Hoffman, 2013). The TSSM places considerable importance on perceived self-efficacy for managing one's symptoms, and provides a basis for developing strategies for increasing self-efficacy. The model depicts that, in addition to being influenced by enhancement strategies, perceived self-efficacy is affected by the symptoms experience, patient characteristics (which parallel the influencing factor categories of the TOUS), and functional and cognitive performance outcomes. Perceived self-efficacy is proposed to impact symptom self-management behaviors, which are also influenced by the symptoms and the performance outcomes. The parallels to the TOUS are many; the major differences are explicit emphasis on perceived self-efficacy, which in the TOUS is viewed

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as a psychological influencing factor, addition of intervention strategies to enhance perceived self-efficacy, and the addition of symptom self- management as a distinct outcome of the symptom experience. With increasing attention to patients' self-managing aspects of their care, the TSSM highlights important considerations.

Assessment of Symptoms The TOUS is relevant to practice and can be used as a framework for nursing assessment or care decisions. Symptom experience is subjective; thus, assessment must be tempered by the notion that the individual's description of the severity or distress associated with a symptom reflects his or her interpretation of that symptom experience. A sensation of the same magnitude might be interpreted quite differently (therefore, rated or described differently) by two individuals. Appropriate symptom assessment and management depend on understanding the symptom involved, the underlying disease or causative factors, the stage of the illness, treatments received previously or concurrently, the patient's prognosis and overall emotional state, and his or her unique life circumstances. Ideally, symptom assessment should paint a total picture for which the TOUS is an excellent guide (Matthie & McMillan, 2013).

The medical history is an important part of symptom assessment. The TOUS can provide a guide because physiological, psychological, and situational factors provide a framework for identifying symptom antecedents. For instance, physiological factors identified from history taking could include physical sequelae of past illness or injury or the history of medication use. Psychological factors identified in history taking could include recent or previous depressive incidents or bouts of anxiety, as well as confusion or uncertainty about the symptoms being experienced. Situational factors identifiable in the history could include family/caregiver issues and living conditions, to include availability of assistance. Symptoms should be assessed using all four dimensions identified in the TOUS as a guide in order to provide a full picture of the individual's experience. This history should be carefully validated by physical examination and diagnostic tests focusing on possible underlying causes of the symptoms (Bickley, 2014; Ferri, 2010).

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Instruments Used in Empirical Testing Symptom measures can either focus on a single symptom (e.g., The Brief Pain Inventory by Daut, Cleeland, and Flaner (1983), and the Fatigue Symptom Inventory by Hann and colleagues (1998)) or address multiple symptoms that are commonly seen in a specific disease entity, the most frequently studied being cancer (e.g., The Memorial Symptom Assessment Scale by Portenoy and colleagues (1994)). Some symptom measures focus only on physical symptoms, while others include both physical and emotional domains. Measures may include only presence, intensity, or frequency, rather than all four dimensions described in the TOUS. Some, such as the Fatigue Symptom Inventory, address both the severity of a symptom and the degree to which it interferes with everyday activities, the latter sometimes used as a proxy measure of distress, for example, Eckhardt et al. (2014) and Fink et al. (2010).

Many instruments have been used to measure the other components of the TOUS as well. Among the most commonly used are those that address performance, particularly functional performance measures, which use individuals' reports of their ADLs and roles or others' observations of activity measures (e.g., ability to walk a given distance or range of motion achieved). Many activity measures are limited because they cannot be used for patients who are in critical condition or at the end stage of life. In addition to the self-report and activity measures, some investigators have used physiological measures, such as spirography or blood values to measure severity of illness. Investigators have also used self-report quality-of-life measures to address performance (e.g., Eckhardt et al., 2014; Hsu & Tu, 2013; So et al., 2013). A few examples of the self-report symptom instruments that have been used in applying or testing the TOUS are described briefly in Table 4.2.

Table 4.2 Examples of Self-Report Instruments Used to Apply TOUS in Research and Practice

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aMcNair, Lorr, and Droppelman (1992), bWaltz, Strickland, and Lenz (2010), cKapella et al. (2006), dMelzack (1975),

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eMendoza et al. (1999), fDaut et al. (1983), gRector, Kubo, and Cohn (1987), hWare and Sherbourne (1992), iRadloff (1977), jPortenoy et al. (1994), kCleeland et al. (2000), lHann, Denniston, and Baker (2000), mHann et al. (1998), nKroenke, Spitzer, and Williams (2001).

Selection of Instruments The use of a particular instrument to measure symptom(s), performance, or influencing factors in research or in clinical practice will depend upon what the researcher or clinician needs to answer the research questions being studied and/or the needs and limitations imposed by a particular population or setting. In general, it is preferable to select an existing instrument than to develop a new one, provided it has a good fit to the situation in which it will be used and established reliability and validity (see Waltz, Strickland, & Lenz, 2010). Using Middle Range Theory in Research 4.1 provides an example of how the TOUS has been used, and how symptoms can be assessed using a single-symptom assessment measure.

Summary The TOUS is grounded in clinical observations, research findings, and scientific collaboration. Basic, interrelated elements of the TOUS are the symptom(s); the physiological, psychological, and environmental variables that influence the symptom experience; and the physical, cognitive, and role performance consequences of the symptom experience. All elements are variable and measurable.

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Symptoms are assumed to vary in intensity, timing and duration, the degree of distress they generate, and the qualitative ways in which they are experienced. They can occur singly or in multiples or clusters. The TOUS has proven to be a comprehensive and useful guide for research and practice with a variety of clinical populations and across an array of international settings.

Critical Thinking Exercises

1. Using the theory of unpleasant symptoms as your guide, what would you look for in an assessment tool for patient symptoms? a. Do you monitor all symptom dimensions, such as how distressing

the symptom is, or do you only ask about symptom severity/intensity?

b. Do you monitor only one symptom or multiple symptoms? 2. In your patient assessment, how would you include the antecedents

to symptoms? 3. How would you use the theory of unpleasant symptoms to plan a

comprehensive intervention to alleviate symptoms? a. What interventions might you plan that would target the

antecedents? b. What would you do to intervene regarding symptom distress?

4. What outcome would you use to assess the effectiveness of your interventions? a. Would you use an outcome measure that focuses on the physical,

role, and/or cognitive performance outcome of symptoms? If so, what measure(s) would that be, specifically?

b. If you were to have symptom alleviation as your outcome measure, which specific measurement tool would you use?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and Analysis of Theory exercise on the TOUS.

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http://thePoint.lww.com/Peterson4e

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PART III Middle Range Theories: Psychological

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5 Self-Efficacy Barbara Resnick

Definition of Key Terms

Mastery experience The most influential of self-efficacy information is the interpreted result of one's previous performance or mastery experience. Individuals engage in tasks and activities, interpret the results of their actions, use the interpretations to develop beliefs about their capability to engage in subsequent tasks or activities, and act in concert with the beliefs created.

Outcome expectations The belief that if a behavior is completed, there will be a certain outcome. Bandura postulates that because the outcomes an individual expects are the result of the judgments of what he or she can accomplish, outcome expectations are unlikely to contribute to predications of behavior.

Self-efficacy People's judgments of their capabilities to organize and execute courses of action required to attain designated types of performances. Self-efficacy beliefs provide the foundation for human motivation, well-being, and personal accomplishment.

Social persuasions Individuals also create and develop self- efficacy beliefs as a result of the social persuasions they receive from others. These persuasions can involve exposure to verbal judgments of others.

Somatic and emotional states Somatic and emotional states, such as anxiety, stress, arousal, and mood, also provide information

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about efficacy beliefs. People can gauge their degree of confidence by the emotional state they experience as they contemplate an action.

Vicarious experience In addition to interpreting the results of their actions, people acquire their self-efficacy beliefs through the vicarious experience of observing others perform tasks. This source of information is weaker than mastery experience in helping to create self-efficacy beliefs, but when people are uncertain about their own abilities or when they have limited prior experience, they are more likely to be influenced by observation reactions.

Introduction Self-efficacy is defined as an individual's judgment of his or her capabilities to organize and execute courses of action. At the core of self- efficacy theory is the assumption that people can exercise influence over what they do. Through reflective thought, generative use of knowledge and skills to perform a specific behavior, and other tools of self-influence, a person will decide how to behave (Bandura, 1977, 1986, 1995, 1997). To determine self-efficacy, an individual must have the opportunity for self- evaluation or the ability to compare individual output to some sort of evaluative criterion. It is this comparison process that enables an individual to judge performance capability and establish self-efficacy expectation.

Historical Background Self-efficacy theory is based on social cognitive theory and conceptualizes person–behavior–environment interaction as triadic reciprocality, the foundation for reciprocal determinism (Bandura, 1977, 1986, 1995, 1997). In the initial study (Bandura, 1977) that led to the development of self- efficacy theory, 33 subjects with snake phobias were randomly assigned to three different treatment conditions: (1) enactive attainment, which included actually touching the snakes; (2) role modeling, or seeing others touch the snakes; and (3) the control group. Results suggested that self-

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efficacy was predictive of subsequent behavior, and enactive attainment resulted in stronger and more generalized (to other snakes) self-efficacy expectations. This early self-efficacy research used an ideal controlled setting in that the individuals with snake phobias were unlikely to seek out opportunities to interact with snakes when away from the laboratory setting. Therefore, there was controlled input of efficacy information. While this ideal situation is not possible in the clinical setting, the theory of self-efficacy has been used to study and predict health behavior change and management in a variety of settings.

Definition of Theory Concepts Bandura, a social scientist, differentiated between two components of self- efficacy theory: self-efficacy and outcome expectations. Self-efficacy expectations are judgments about personal ability to accomplish a given task. Outcome expectations are judgments about what will happen if a given task is successfully accomplished. Self-efficacy and outcome expectations were differentiated because individuals can believe that a certain behavior will result in a specific outcome; however, they may not believe that they are capable of performing the behavior required for the outcome to occur.

The types of outcomes people anticipate generally depend on their judgments of how well they will be able to perform the behavior. Those who consider themselves to be highly efficacious in accomplishing a given behavior will expect favorable outcomes for that behavior. Expected outcomes are dependent on self-efficacy judgments. Therefore, Bandura postulated that expected outcomes may not add much on their own to the prediction of behavior. Bandura (1977) does state, however, that there are instances when outcome expectations can be dissociated from self-efficacy expectations. This occurs either when no action will result in a specific outcome or when the outcome is loosely linked to the level or quality of the performance. For example, if Mrs. White knows that even if she regains functional independence by participating in rehabilitation, she will still be discharged to a skilled nursing facility rather than back home; her behavior is likely to be influenced by her outcome expectations (discharge to the skilled nursing facility). In this situation, no matter what Mrs. White's performance is, the outcome is the same; thus, outcome expectancy may influence her behavior independent of her self-efficacy

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beliefs. Expected outcomes are also partially separable from self-efficacy

judgments when extrinsic outcomes are fixed. For example, when a nurse provides care to six patients during an 8-hour shift, the nurse receives a certain salary. When the same nurse cares for 10 patients during the same shift, she receives the same salary. This could negatively impact performance. It is also possible for an individual to believe that he or she is capable of performing a specific behavior but not believe that the outcome of performing that behavior is worthwhile. For example, older adults in rehabilitation may believe that they are capable of performing the exercises and activities involved in the rehabilitation process but may not believe that performing the exercises will result in improved functional ability. Some older adults believe that resting rather than exercising will lead to recovery. In this situation, outcome expectations may have a direct impact on performance.

Outcome expectations are particularly relevant to older adults. These individuals may have high self-efficacy expectations for exercise, but if they do not believe in the outcomes associated with exercise, for example, improved health, strength, or function, then it is unlikely that there will be adherence to a regular exercise program.

Sources of Self-Efficacy Judgment Bandura (1986) suggested that judgment about one's self-efficacy is based on four informational sources: (1) enactive attainment, which is the actual performance of a behavior; (2) vicarious experience or visualizing other similar people perform a behavior; (3) verbal persuasion or exhortation; and (4) physiological state or physiological feedback during a behavior, such as pain or fatigue. The cognitive appraisal of these factors results in a perception of a level of confidence in the individual's ability to perform a certain behavior. The positive performance of this behavior reinforces self- efficacy expectations (Bandura, 1995).

Enactive Attainment Enactive attainment has been described as the most influential source of self-efficacy information (Bandura, 1977, 1986). There has been repetition

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in empirical verification that actually performing an activity strengthens self-efficacy beliefs. Specifically, self-efficacy and outcome expectations play an influential role in the performance of functional activities (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2009; van den Akker- Scheek et al., 2007), adoption and maintenance of exercise behavior (Hays, Pressler, Damush, Rawl, & Clark, 2010; Lee, Arthur, & Avis, 2008; Resnick, Luisi, & Vogel, 2008; Resnick, Shaughnessy, et al., 2009), and optimal self-management of numerous clinical problems such as congestive heart failure (Hiltunen et al., 2005; Padula, Yeaw, & Mistry, 2009), diabetes (Hunt, Grant, & Pritchard, 2012), peritoneal dialysis (Su, Lu, Chen, & Wang, 2009), depression (Weng, Dai, Wang, Huang, & Chiang, 2008), and back pain (Göhner & Schlicht, 2006). Enactive attainment generally results in greater strengthening of self-efficacy expectations than do informational sources.

However, performance alone does not establish self-efficacy beliefs. Other factors, such as preconceptions of ability, the perceived difficulty of the task, the amount of effort expended, the external aid received, the situational circumstance, and past successes and failures all impact the individual's cognitive appraisal of self-efficacy (Bandura, 1995). An older adult who strongly believes that he or she is able to bathe and dress independently because he or she has been doing so for 90 years will not likely alter self-efficacy expectations if he or she wakes up with severe arthritic changes one morning and is consequently unable to put on a shirt. However, repeated failures to perform the activity will impact self-efficacy expectations. The relative stability of strong self-efficacy expectations is important; otherwise, an occasional failure or setback could severely impact both self-efficacy expectations and behavior.

Vicarious Experience Self-efficacy expectations are also influenced by vicarious experiences or seeing other similar people successfully performing the same activity. There are some conditions, however, which impact the influence of vicarious experience. If the individual has not been exposed to the behavior of interest, or has had little experience with it, vicarious experience is likely to have a greater impact. In addition, when clear guidelines for performance are not explicated, self-efficacy will be more likely to be impacted by the performance of others. Likewise, self- modeling has been noted to influence self-efficacy and outcome

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expectations and specifically was noted to strengthen self-efficacy expectations and related behavior in older adults with diabetes. Such things are kept as personal records of behavior (Haylock, 2010; Resnick, Shaughnessy, et al., 2009).

Verbal Persuasion Verbal persuasion involves telling an individual that he or she has the capabilities to master the given behavior. Empirical support for the influence of verbal persuasion has been documented since Bandura's early research of phobias (Bandura, 1977). Verbal persuasion has proven effective in supporting recovery from chronic illness and in health promotion research. Persuasive health influences lead people with a high sense of self-efficacy to intensify efforts at self-directed change of risky health behavior. For example, in rehabilitation settings, verbal persuasion by a nurse had a positive impact on self-efficacy expectations and participation in rehabilitation (Hiltunen et al., 2005), as well as participation in exercise (Galik et al., 2008; Resnick, Gruber-Baldini, Zimmerman, et al., 2009). In nursing, educational interventions are often used as a way to provide verbal encouragement. Multiple examples of this exist in areas such as diet interventions (Sharp & Salyer, 2012) and other health-promoting behaviors such as exercise, medication adherence, or cancer screening (Edmonds, 2010; Hsiao-Lan et al., 2014; Kauric-Klein, 2012).

Physiological Feedback Individuals rely in part on information from their physiological state in order to judge their abilities. Physiological indicators are especially important in relation to coping with stressors, physical accomplishments, and health functioning. Individuals evaluate their physiological state, or arousal, and if aversive, they may avoid performing the behavior. For example, if the older adult has a fear of falling or getting hurt when walking, a high arousal state associated with the fear can limit performance and decrease the individual's confidence in ability to perform the activity. Likewise, if the rehabilitation activities result in fatigue, pain, or shortness of breath, these symptoms may be interpreted as physical inefficacy, and the older adult may not feel capable of performing the activity.

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Interventions can be used to alter the interpretation of physiological feedback and help individuals cope with physical sensations, enhancing self-efficacy and resulting in improved performance. Interventions include things such as elimination of pain, fear of falling, or shortness of breath associated with physical activity (Coleman, 2011; Resnick & D'Adamo, 2011).

Relationships Among the Concepts: The Model The theory of self-efficacy was derived from social cognitive theory and must be considered within the context of reciprocal determinism. The four sources of experience (direct experience, vicarious experience, judgments by others, and derivation of knowledge by inference) that can potentially influence self-efficacy and outcome expectations interact with characteristics of the individual and the environment. Ideally, self-efficacy and outcome expectations are strengthened by these experiences and subsequently moderate behavior. Since self-efficacy and outcome expectations are influenced by performance of a behavior, it is likely that there is a reciprocal relationship between performance and efficacy expectations.

Application of the Theory in Research The theory of self-efficacy has been used in nursing research, focusing on clinical aspects of care, education, nursing competency, and professionalism. There have been hundreds of articles in nursing journals using self-efficacy to guide interventions and predict behavior. While the focus of the articles ranges from management of chronic illnesses to education of nurses and parental training, the majority have been related to chronic health problems and participation in health-promoting activities such as exercise, smoking cessation, and weight loss.

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The majority of these studies are descriptive in nature, exploring the relationship between self-efficacy expectations and behavior. Although more and more intervention studies are being guided by self-efficacy expectations (Ireland et al., 2010; Meraviglia, Stuifbergen, Parsons, & Morgan, 2013; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011; Resnick et al., 2011), the interventions continue to focus mainly on mastery experiences and verbal encouragement usually through education. Although limited, there is some work that is beginning to address the impact of dose effect of the intervention in terms of strengthening self- efficacy (Resnick et al., 2011) and testing the impact of different sources of efficacy information (Resnick et al., 2011). Some research in nursing has shown, for example, that mastery alone was not noted to be more effective than verbal encouragement, physiological feedback, or cueing with self-modeling (Resnick et al., 2007). The most important factor with regard to the use of the theory of self-efficacy in nursing research is that the researcher maintains the behavioral specificity of self-efficacy by developing a fit between the behavior that is being considered and the efficacy and outcome expectations being measured. If the behavior of interest is walking for 20 minutes every day, the self-efficacy measure should focus on the challenges related to this specific behavior (time, fatigue, pain, or fear of falling associated with walking).

Self-efficacy Studies Related to Health Behaviors Self-efficacy has been used to improve and understand health behaviors with regard to exercise (Donesky et al., 2011; Resnick, Michael, Griffith, Klinedinst, & Galik, 2014). Specifically, these nursing studies considered the impact of motivational interventions and engaging individuals in exercise activities on self-efficacy expectations and explored relationships between self-efficacy and outcome expectations and exercise behavior. In contrast to Bandura's earlier findings (Bandura, 1997), which stressed that self-efficacy expectations were better predictors of behavior than were outcome expectations, in several nursing studies, outcome expectations, rather than self-efficacy expectations, were predictive of exercise behavior (Morrison & Stuifbergen, 2014; Weekes, Haas, & Gosselin, 2014).

Self-efficacy theory has also been used to address health behaviors such as eating a heart-healthy diet (Sharp & Salyer, 2012), smoking

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cessation using innovative approaches such as education following screening (Poghosyan, Sheldon, & Cooley, 2012), management of bone health via an online intervention (Resnick et al., 2014), and screening for colorectal cancer (Hsiao-Lan et al., 2014) among others. In all of these studies, there was consistently a strong association between self-efficacy and the stated health behavior.

Self-Efficacy and Cultural and Nursing Care Competence Cultural competence in nurses has been considered by using a measure of knowledge of cultural concepts, knowledge of cultural life patterns for specific ethnic groups, and self-efficacy in performing cultural nursing skills (Messler, 2014). Findings indicated that nurses were moderately efficacious in cultural knowledge and abilities. Advanced practice nursing students' self-efficacy expectations associated with being able to diagnose depression have also been considered (Delaney & Barrere, 2012). Confidence, or self-efficacy, in being able to identify depression was associated with providing holistic and comprehensive nursing care to adult patients. Self-efficacy expectations associated with dementia care management is another area that has been explored (Connor et al., 2009) as has self-efficacy for providing function-focused care (FFC) across a variety of clinical settings (Resnick, Gruber-Baldini et al., 2009, 2011, 2014). Self-efficacy expectations were associated with the nursing care behaviors of interest (e.g., providing FFC). Self-efficacy expectations have not, however, been associated with turnover among nurses in clinical settings (Lee, Lim, Jung, & Shin, 2012).

Self-Efficacy and Functional Performance Self-efficacy has been considered with regard to functional performance, particularly with regard to adults undergoing orthopedic interventions (Brady, Straight, & Evans, 2014; Resnick, Galik, et al., 2009; Sullivan, Espe, Kelly, Veilbig, & Kwasny, 2014; van den Akker-Scheek et al., 2007). Across all these studies, there was an association between self-

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efficacy expectations and functional performance.

Self-Efficacy and Patient Self- Management Nursing research frequently uses self-efficacy theory to address self-care and self-management across a variety of clinical problems. For example, self-efficacy has been used with regard to self-care management of post– acute cardiac events and associated with congestive heart failure self- management (Padula et al., 2009; Sharp & Salyer, 2012), diabetes self-care management (Hunt et al., 2012; Utz et al., 2008), self-management for peritoneal dialysis (Su et al., 2009), managing depression (Weng et al., 2008), and self-management of chronic obstructive pulmonary disease (Donesky et al., 2014; Lee et al., 2013). Nursing interventions intended to improve adherence to self-care behaviors were guided by self-efficacy theory in these studies, and findings indicated that there were improvements in self-efficacy as well as anticipated behaviors. Using Middle Range Theory in Research 5.1 provides a description of a study that uses self-efficacy for the framework to improve outcomes in individuals with heart failure. Self-efficacy–based interventions have also been used to help adults manage multiple chronic illnesses. Specifically, education during a 2-hour workshop focused on management of chronic illness by building patient-directed skills such as medication management. This intervention was noted to improve health and quality of life among older adults with multiple chronic illnesses (Hochhalter, Song, Rush, Sklar, & Stevens, 2010).

USING MIDDLE RANGE THEORY IN RESEARCH 5.1

Source: Padula, C. A., Yeaw, E., & Mistry, S. (2009). A home-based nurse-coached inspiratory muscle training intervention in heart failure. Applied Nursing Research, 22(1), 18–25.

Purpose/Research Question

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The purpose of this study, using self-efficacy as a theoretical framework, was to compare the effectiveness of home-based inspiratory muscle training (IMT) to educational materials in improving IM strength, reducing dyspnea, improving self-efficacy for breathing, and higher levels of health-related quality of life.

Research Design The study followed a two-group, quasi-experimental research

design using self-efficacy as a theoretical framework.

Subjects/Participants Subjects were recruited from physician's offices, home care

agencies, provider referral, and newspaper advertisements. To be included in the study, subjects had to be adult, community dwelling, medically stable, and without coexisting pulmonary disease or cognitive impairment. Thirty-six subjects out of the 288 who were screened were found to be eligible; of those 36, 32 agreed to participate.

Data Collection Subjects diagnosed with heart failure and dyspnea were randomly

assigned via a coin toss to one of two groups, the treatment group, which received individual training to improve breathing, or the control group, which received standard educational materials. The treatment group comprised 15 subjects and the control group 17 subjects.

The individual training consisted of a demonstration of the threshold device by a nurse research assistant with return demonstration. The subjects then trained with the device daily, 10 to 20 min/d for a week. The control group received a booklet that addressed basic anatomy and physiology of the heart, health regimes related to diet, medication, sleep and rest, and activity patterns. It also advised on what and when to report to their physician and incorporated principles of self-efficacy.

The two groups were compared to inspiratory muscle strength (IMS) measured by pulmonary inspiration score; dyspnea, using the Borg scale and the Chronic Respiratory Disease Questionnaire (CRDQ); and self-efficacy with the COPD Self-Efficacy scale. Data were collected over a 12-week period.

Nursing Implications

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The training group experienced increased IM strength (48.72 ± 25.69 to 78.5 ± 37.08), whereas the educational group remained unchanged (52.25 ± 27.32 to 52.61 ± 28.25). There was a statistically significant difference in the experience of dyspnea between the two groups as measured by rankings on shortness of breath with three activities at baseline, 6 weeks, and 12 weeks. Between 6 and 12 weeks, p = 0.027. There were no statistically significant differences in COPD Self-Efficacy scale scores between the two groups.

Self-efficacy provided the framework for both the individual training of subjects and the education materials created and provided to subjects. The study did conclude that nurse-coached, home-based IMT is a safe and effective approach to improving IMS.

Self-Efficacy and Breast-Feeding and Infant Care Another common use of self-efficacy theory in nursing research is around the area of mothering, specifically with regard to breast-feeding and infant care (Zhu, Chan, Zhou, Ye, & He, 2014; de Jager Broadbent, Fuller- Tyszkiewicz, &, Skouteris, 2014). Self-efficacy expectations were shown to be associated with breast-feeding and infant care, and interventions to strengthen self-efficacy associated with these behaviors improved adherence to nursing behaviors.

Self-Efficacy and Cancer Care Nurse researchers in the area of oncology identified relationships among self-efficacy, cancer prevention, and adaptation to cancer. Strong self- efficacy expectations predict behaviors such as intention to quit smoking, increased participation in screening programs, and adjustment to cancer diagnosis (Becker, Mackert, & Kang, 2013; Griffiths, Kidd, Pike, & Chan, 2010; Jennings-Sanders, 2009; Park, Song, Hur, & Kim, 2009). Increased self-efficacy is associated with increased adherence to treatment, increased self-care behaviors, and decreased physical and psychological symptoms.

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Self-Efficacy for Bone Health Self-efficacy interventions have been used to increase adherence to behaviors that are consistent with good bone health such as high-calcium diets and exercise (Nahm et al., 2010; Resnick et al., 2014). These studies have been both descriptive and have used education and mastery experiences to strengthen self-efficacy expectations in exercise focused on bone strengthening, adherence to bone building medications, and diet.

Self-Efficacy for Fall Prevention Self-efficacy interventions have been used to strengthen self-efficacy expectations related to fear of falling (Visschedijk, van Balen, Hertogh, & Achterberg, 2013; Ying-Yu, Scherer, Yow-Wu, Lucke, & Montgomery, 2013). Consistently, fear of falling is associated with falls self-efficacy or the confidence that individuals have that they can do routine activities without falling. Strengthening fear of falling is assumed to result in increased performance of the behavior of interest.

Self-Efficacy for Exercise Resnick (Galik et al., 2008; Resnick, Galik, et al., 2009; Resnick, Gruber- Baldini, Zimmerman, et al., 2009), using combined quantitative and qualitative approaches, demonstrated that self-efficacy and outcome expectations influence older adults' participation in functional activities and exercise. Based on these findings, interventions were developed to strengthen self-efficacy and outcome expectations related to these activities. Overall, this work uses self-efficacy theory to encourage healthy behaviors such as engaging in regular exercise. The work by Resnick and her interdisciplinary team started with qualitative research to explore factors that influenced motivation to engage in such behaviors (Resnick & Spellbring, 2000; Resnick, Luisi, et al., 2008). Once identified through qualitative study, specific challenges and benefits of performing exercise were used to develop the self-efficacy and outcome expectation scales that were appropriate for this behavior. Development of self-efficacy expectation measures was based on Bandura's (1977) early work with snake phobias. This approach included a paper and pencil measure that

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listed activities, from least to most difficult, in a specific behavioral domain. Respondents were given a 100-point scale, divided into 10-unit intervals ranging from 0, which is completely uncertain, to 10, which is completely certain, to identify the extent of confidence they had in performing a particular activity (strength of self-efficacy) given the existence of a challenge or benefit. An example of items on a self-efficacy scale for exercise follows:

How confident are you right now that you could exercise three times per week for 20 minutes if:

The development of appropriate self-efficacy and outcome expectation measures enables the testing of interventions designed to help participants believe in the benefits and overcome the challenges of performing selected activities. Examples of how this has been done are demonstrated in the WALC (Walk, Address unpleasant symptoms, Learn about exercise, Cueing to exercise) intervention and the Exercise Plus Program (Resnick et al., 2007), the Senior Exercise Self-efficacy Project (Resnick, Luisi, et al., 2008), PRAISEDD, an exercise intervention program for minority older adults living in senior housing (Resnick et al., 2014; Resnick, Shaughnessy, et al., 2009), and multiple FFC interventions in nursing homes (Galik et al., 2008; Resnick, Gruber-Baldini, Galik, et al., 2009; Resnick, Gruber-Baldini, Zimmerman, et al., 2009; Resnick et al., 2011). All of these interventions incorporate the four sources of information known to influence self-efficacy and outcome expectations. Specifically, they use verbal encouragement, decreasing unpleasant sensations, cueing and role modeling, and the actual performance of the behavior.

Self-efficacy theory has been used as a foundation for FFC programs that encourage functional and physical activity in older adults in a variety of settings (Pretzer-Aboff, Galik, & Resnick, 2011; Resnick et al., 2011) and that increase direct care worker (DCW) performance of FFC. A detailed description of this intervention, referred to as FFC, is provided in

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Box 5.2.

BOX 5.2 Function-Focused Care in Assisted Living (FFC-AL) Intervention

Following pilot testing (Resnick et al., 2009), FFC-AL was tested using a cluster-randomized controlled trial with a repeated measure design (Resnick, Galik, et al., 2011). The intervention persisted, and participants were followed over a 12-month period. A total of four AL communities were matched on ownership, and all were similar in size, staffing, and services. A total of 171 residents and 96 DCWs were recruited from these sites.

The FFC-AL intervention was coordinated and implemented by a research Function-Focused Care Nurse (FFCN) with support from an interdisciplinary research team that included advanced practice nurses, social work, and physical therapy. The FFCN worked with the intervention sites 15 hours per week for the first 6 months of the intervention, 8 hours a week for the next 3 months, and 4 hours a week for the final 3 months of the intervention. To assure sustainability of the FFC philosophy, each treatment site identified a staff champion who worked with the FFCN, learned the four components necessary to implement and sustain the FFC philosophy, and helped to institutionalize FFC within the community. Working with the champion, the FFCN implemented the four components of FFC-AL: (1) environment and policy/procedure assessments, (2) education, (3) developing function- focused goals, and (4) mentoring and motivating.

Components were implemented sequentially although overlapped in that once initiated they continued throughout the course of the intervention. Component 1 involved having the FFCN evaluate the environment and community policies and procedures to determine if they presented barriers to implementation of an FFC approach. Environments, for example, were evaluated for pleasant walking areas, destination sites, and appropriate bed and chair heights. Findings were discussed during the course of the 12-month study period with AL administrative staff to facilitate appropriate changes. Component 2, the education component, was then implemented, and all staff were invited to attend a 30-minute session on implementing an FFC approach (e.g., benefits of FFC, motivational strategies to engage residents, and recommendations for

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how to incorporate FFC into routine care activities). Component 3, individual goal setting, was initiated by the FFCN

working closely with the resident, staff champion, and DCWs. Residents' physical capability was evaluated using a Physical Capability Assessment form. This assessment evaluated cognitive status and functional ability (e.g., range of motion and balance) of residents. Goals included things such as walking to the dining room, going to exercise classes, or engaging in personal care activities. Once individual goals were established for all participants, Component 4, mentoring and motivating, was initiated. This involved the FFCN and community champion mentoring DCWs and helping them motivate residents to work toward goal achievement. Motivational interventions were used to reward and recognize staff for providing FFC and residents for participating in exercise-related activities. Ongoing informal education and positive role modeling at the bedside related to FFC was provided by the FFCN and staff champion throughout the course of the 12-month intervention.

AL communities randomized to control received FFC-Education only. All staff in these communities were invited to attend an educational session on FFC. The education material was identical to that provided to the treatment group, with the exclusion of motivational techniques, to engage residents in functional and physical activity.

Study Results The majority of the DCWs were female (n = 95; 99%) and black (n =

59; 62%), with a mean age of 41.7 years (SD = 13.8). The residents were mostly female (80%), white (93%), and widowed (80%) with a mean age of 87.7 years (SD = 5.7). Outcomes for residents included psychosocial domains (mood, resilience, and self-efficacy and outcome expectations for function and physical activity), function, gait and balance, and actigraphy. Outcomes for DCWs included knowledge, performance, and beliefs associated with FFC.

Based on observations, DCWs in treatment sites provided more FFC by 12 months than did those in the control sites. The treatment group increased from providing FFC during 76% of observed care interactions at baseline to 82% at 4 months and 90% at 12 months (p = 0.001) compared to the control group, which provided FFC during 75% of care interactions at baseline and 4 months and then this decreased to 69% of care interactions at 12 months.

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Residents in treatment sites demonstrated less decline in function, a greater percentage returned to ambulatory status, and there were positive trends demonstrating more time in moderate level physical activity at 4 months and more overall counts of activity at 12 months when compared to residents in control sites. Specifically, the control group declined 6.95 points versus 4.33 points for the treatment group, p = 0.01, in overall function based on the Barthel Index (scores range from 0 to 100 with higher scores indicative of more independent function). From baseline to 12 months, 13 (17%) residents in the treatment group versus 2 (4%) residents in the control group resumed walking functional distances versus remaining wheelchair dependent (chi square = 4.94, p = 0.026). Although not significantly different, residents in the intervention group showed a greater increase in the amount of time spent in moderate-level physical activity at 4 months (p = 0.08). Specifically, the treatment group increased from 0.43 at baseline to 1.00 minute of moderate-level physical activity with 24 hours versus the control group, which had a decline from 0.51 to 0.35 minutes. In addition, the treatment group had an increase in counts of activity from 40,668 at 4 months to 46,960 at 12 months, while the control group declined from 36,834 at 4 months to 32,563 at 12 months (p = 0.07). There were no treatment effects on residents' self- efficacy or outcome expectations, mood, resilience, balance, or gait.

This study supports the use of FFC-AL to change care behaviors among DCWs and suggests that FFC-AL may help prevent some of the persistent functional decline and sedentary behavior commonly noted in these settings.

Source: Resnick, B., Galik, E., Gruber-Baldini, A., & Zimmerman, S. (2009). Implementing a restorative care philosophy of care in assisted living: Pilot testing of Res-Care-AL. Journal of the American Academy of Nurse Practitioners, 21(2), 123–133; Resnick, B., Galik, E., Gruber- Baldini, A., & Zimmerman, S. (2011). Testing the impact of function focused care in assisted living. Journal of the American Geriatrics Society, 59(12), 2233–2240.

Application of the Theory in Practice Translation of research findings into practice is not often done in a timely fashion. This is particularly true of research findings that focus on

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behavior change. There is, however, evidence to demonstrate that the theory of self-efficacy can help direct nursing care. The theory has been particularly helpful with regard to motivating individuals to participate in health-promoting activities such as regular exercise, smoking cessation, weight loss, and going for recommended cancer screenings. Table 5.1 provides examples of studies conducted to test the usefulness of the theory with different populations and desired treatment outcomes.

Table 5.1 Examples of Research for Application to Practice

The ultimate goal of any intervention implemented in a research setting is to maintain the intervention over time and persist in day-to-day clinical practice. FFC interventions are developed so as to be integrated into routine care and continue even at the end of the research activities. It has been demonstrated that FFC interventions persist in clinical settings.

In clinical practice, FFC, like any innovative intervention, requires a champion. The champion can be self-identified or identified by administrative staff to take on the project or focus of care. Assisted living (AL) communities that have successfully implemented FFC have been identified as such a champion. This individual varied in terms of professional level and administrative position. The individual, however,

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believed in the benefit of optimizing function and physical activity among older adults and was passionate about helping other caregivers to achieve that type of care. Using Middle Range Theory in Practice 5.3 provides a description of the theory applied to an FFC intervention.

USING MIDDLE RANGE THEORY IN PRACTICE 5.3

The theory of self-efficacy served as the foundation for the development of an FFC intervention for assisted living (FFC-AL) settings that was used to teach and motivate nursing assistants to provide FFC to residents of AL settings.

Source: Resnick, B., Galik, E., Gruber-Baldini, A., & Zimmerman, S. (2011). Testing the impact of function focused care in assisted living. Journal of the American Geriatrics Society, 59(12), 2233–2240.

Problem The majority of older adults who live in AL communities need

assistance with bathing, dressing, toileting, and locomotion. They suffer with multiple comorbidities, and many have at least mild comorbidity. They tend to decline in function, engage in limited physical activity, are more likely to become depressed, and experience a lower quality of life. Changes need to be made in the way care is delivered to the residents of AL communities.

Nursing Intervention This particular project introduced the FFC philosophy into four AL

settings in the greater Baltimore area. FFC is a philosophy of care in which nurses acknowledge older adults' physical and cognitive capabilities (e.g., ambulation, hygiene activities) and engage the adults in these activities, integrating them into routine care.

Nursing assistants attended an in-service program that introduced them to (1) the philosophy of FFC in this program, contrasting it to more traditional approaches; (2) motivational strategies based on the theory of self-efficacy; (3) integration of FFC activities with personal care activities (bathing, dressing, and feeding); (4) setting resident goals

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and integration of FFC activities (exercise) during transfers and ambulation; and (5) overcoming challenges in providing FFC. Residents were encouraged, for example, to engage in bed mobility at their highest level; walk to the dining room if having the underlying capability to do so rather than be pushed in a wheelchair; or attend an exercise class. The effectiveness of this approach was evaluated using a number of outcome measures.

Conclusions It was determined that the intervention accounted for some

improvement in function and time spent in physical activity and the nursing assistants spent more time providing FFC rather than simply completing the care task for the resident.

Evaluation of the Environment and Policies The first step in the implementation of an FFC approach is to evaluate the current environment and policies within the community. Policy and environmental changes should be established to facilitate implementation of FFC approaches with staff and residents. The communities altered their environments to optimize function in simple ways by doing such things as setting up pleasant and safe walking areas, so there were chairs for residents to sit in to rest, clutter was removed from residents' living spaces to encourage ambulation, and new exercise-focused classes were developed for resident activities to replace sedentary activities. Policy changes included new Service Plan Forms, which are required in AL communities. The new Service Plan Forms included FFC goals for all residents. The FFC goals delineated what the resident was required to do with regard to function and physical activity and how the DCW would help the resident achieve those goals (e.g., remind the individual to go to exercise class).

Self-efficacy–based mentoring and motivation of staff occurs via ongoing formal and informal education of DCWs. Following basic education of all staff during a single 30-minute in-service program, all new staff must go through an FFC training module and pass the FFC knowledge test with a score of 80% or greater, or repeat the module. The

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champion provides monthly oversight to DCWs in these communities during monthly observations of an interaction between a DCW and a resident and provides positive feedback regarding ways in which the DCW encouraged and facilitated function and physical activity. Verbal encouragement is provided to the DCW to continue these positive interventions and examples, and role modeling provided to increase functional engagement and physical activity of the resident during routine care activities.

Reward systems are established within clinical settings for the DCWs and the residents. DCWs are recognized with gold stars on a bulletin board to indicate their exemplary performance of FFC during observations. Rewards for residents include a program called “Gifts of the Heart.” Residents receive tokens or tickets for participating in FFC activities (e.g., a resident who walked to the dining room or attended an exercise class). Residents collect their tokens and then trade them for prizes from a glass display case of gifts.

Taken together, the verbal encouragement through education and goal setting, role modeling, ongoing awareness and changes in the environment and policies to eliminate unpleasant sensations around function and physical activity (e.g., providing places for the residents to rest), and the strengthening of self-efficacy that occurs as DCWs and residents engage in FFC activities assure that this innovative philosophy of care persists in the clinical setting.

Summary The studies done by nurse researchers using the theory of self- efficacy provide support for the importance of self-efficacy and outcome expectations with regard to behavior change. Studies also provide support for the effectiveness of specific interventions that have been tested to strengthen both self-efficacy and outcome expectations and thereby improve behavior. Other variables such as tension/anxiety, barriers to behavior, and other psychosocial experiences impact behavior. Bandura (1986) recognized that expectations alone would not result in behavior change if there was no incentive to perform, or if there were inadequate resources or external constraints.

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Increasingly, it is recognized that use of a comprehensive social– ecological model (SEM) approach, which incorporates intrapersonal, interpersonal (including social networks), environmental, and policy factors, is needed to positively influence preventive health behaviors (Sallis et al., 2006). Self-efficacy theory is situation specific. It is difficult, therefore, to generalize an individual's self-efficacy from one type of behavior to another. Future nursing research needs to focus on the degree to which specific self-efficacy behaviors can be generalized. To what degree is self-efficacy a dimension of individual humanness, distinct for each person, but consistent across a range of related behaviors for one person? Measurement of self-efficacy and outcome expectations requires the development of valid and reliable, situation-specific scales with a series of activities listed in order of increasing difficulty, or by a contextual arrangement in nonpsychomotor skills, such as dietary modification (Marchante et al., 2014; Resnick, 2002; Sterling, Ford, Park, & McAlister, 2014). Scales that are behavior specific can be used as the foundation for assessing an individual's self-care abilities in a particular area. Interventions can then be developed that are relevant for that individual. Current research, as part of the Patient Reported Outcomes Measurement Information System (PROMIS) Program, will hopefully add to the knowledge of measurement of self-efficacy by assuring that the full spectrum of behaviors associated with management of chronic illness and the challenges encountered by patients with regard to those behaviors (e.g., confidence driving at night) are addressed. A major problem with the use of the theory of self-efficacy in nursing research has been the lack of consideration of outcome expectations. In particular, with regard to exercise in older adults, outcome expectations have been noted to be better predictors of exercise behavior than self-efficacy expectations (Ferrier, Dunlop, & Blanchard, 2010; Resnick, 2002; Resnick et al., 2014; Sirur, Richardson, Wishart, & Hanna, 2009). Consideration also needs to be given to the influence of self-efficacy expectations beyond the initiation of behavior to focus more on long- term adherence. Clearly, social cognitive theory and the theory of self-efficacy have

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helped guide nursing research related to behavior change. Ongoing studies are needed to continue to evaluate the impact of both self-efficacy and outcome expectations on behavior change, as well as develop and test interventions that strengthen these expectations.

Critical Thinking Exercises

1. As a nurse on a medical surgical unit, you are getting ready to discharge a patient home who has just had a hip fracture and an open reduction internal fixation to repair the fracture. She is independent with ambulation using her walker and will have some home physical therapy. Of note, however, she had a bone density scan that indicated severe osteoporosis and has been started on a bisphosphonate and calcium. Your goal at discharge is to increase the likelihood that she will adhere to taking these medications. Address the interventions you would do to ensure this.

2. You have just moved to New Mexico and are very concerned about working with a large percentage of Spanish-speaking older adults. You know little about their culture. Address what interventions you might do for yourself to facilitate this transition in your nursing career.

3. You have just started working on a maternity ward and noted that the mothers admitted who are younger than 20 years of age have a great deal of difficulty with the idea of breast-feeding and how to begin to breast-feed. Develop an intervention that you could implement to optimize your nursing interventions with these individuals.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Self-Efficacy.

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6 Chronic Sorrow Georgene Eakes

Definition of Key Terms

Chronic sorrow Periodic recurrence of permanent, pervasive sadness or other grief-related feelings associated with ongoing disparity resulting from a loss experience

Loss experience A significant loss, either actual or symbolic, that may be ongoing with no predictable end or a more circumscribed single loss event

Disparity A gap between the current reality and the desired as a result of a loss experience

Trigger event A situation or circumstance or condition that brings the negative disparity resulting from the loss into focus or exacerbates the disparity

Internal management methods Positive personal coping strategies used to deal with the periodic episodes of chronic sorrow

External management methods Interventions provided by professionals to assist individuals cope with chronic sorrow

Introduction

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The middle range theory of chronic sorrow, first documented in the literature in 1998 by Eakes, Burke, and Hainsworth, offers a framework for explaining how individuals may respond to both ongoing and single loss events. Moreover, the theoretical model of chronic sorrow provides an alternative way of viewing the experience of grief. The theory of chronic sorrow was inductively derived and subsequently validated from an extensive review of the literature and from the data gathered through 10 qualitative research studies conducted by members of the Nursing Consortium for Research on Chronic Sorrow (NCRCS). Using the Burke/NCRCS Chronic Sorrow Questionnaire, adapted from a guide developed by Burke (1989), as an interview guide, these nurse researchers interviewed 196 individuals who shared their loss experiences as people with chronic conditions, as family caregivers of the chronically ill or disabled, or as bereaved family members.

Historical Background The term chronic sorrow was introduced into the literature over 50 years ago to characterize the recurring episodes of grief experienced by parents of children with disabilities (Olshansky, 1962). This recurring sadness appeared to persist throughout the lives of these parents, although its intensity varied from time to time, from situation to situation, and from one family member to another. Rather than viewing this phenomenon as pathological, Olshansky described chronic sorrow as a normal response to an ongoing loss situation. Professionals were encouraged to recognize the presence of this phenomenon when working with a parent of a disabled child and to support parents' expressions of feelings. Although the term gained wide acceptance in the professional literature, almost two decades passed before there was any documented research on chronic sorrow.

Initial research conducted in the 1980s validated the occurrence of chronic sorrow among parents of disabled young children. Several investigators suggested that the never-ending nature of the loss of the “perfect” child prevented resolution of grief (Burke, 1989; Damrosch & Perry, 1989; Fraley, 1986; Kratochvil & Devereaux, 1988; Wikler, Wasow, & Hatfield, 1981). Moreover, it was this inability to bring closure to the loss experience that was thought to precipitate periodic episodes of re-grief labeled as chronic sorrow. These early studies refined and operationalized the definition of chronic sorrow as a pervasive sadness that

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was permanent, periodic, and progressive in nature.

Current Research on Chronic Sorrow More recent research supports the fact that chronic sorrow is a common experience among family caregivers (Bettle & Latimer, 2009; Bowes, Lowes, Warner, & Gregory, 2009; Clubb, 1991; Copley & Bodensteiner, 1987; Doornbos, 1997; Eakes, 1995; Eakes, Burke, Hainsworth, & Lindgren, 1993; Fraley, 1990; George & Vickers, 2006–2007; Golden, 1994; Gordon, 2009; Hainsworth, 1995; Hainsworth, Busch, Eakes, & Burke, 1995; Hobdell, 2004; Hobdell et al., 2007; Hummel & Eastman, 1991; Johnsonius, 1996; Keamy & Griffin, 2001; Krafft & Krafft, 1998; Liedstrom, Isaksson, & Ahlström, 2008; Lindgren, 1996; Lowes & Lyne, 2000; Mallow & Bechtel, 1999; Mayer, 2001; Northington, 2000; Patrick- Ott & Ladd, 2010; Phillips, 1991; Rosenberg, 1998; Rossheim & McAdams, 2010; Seideman & Kleine, 1995; Shumaker, 1995; Whittingham, Wee, Sanders, & Boyd, 2012). The caregivers studied represent parents of young children with various disabilities, spouses of individuals diagnosed with chronic illnesses, and parents of adult children with debilitating conditions.

The NCRCS, established in 1989 (Eakes, Hainsworth, Lindgren, & Burke, 1991), expanded research on chronic sorrow and explored the relevance of the concept of chronic sorrow among individuals experiencing a variety of loss situations. This group of nurse researchers not only conducted research on chronic sorrow among family caregivers but also investigated individuals affected with chronic conditions and bereaved individuals. Among those diagnosed with a chronic condition, 83% evidenced chronic sorrow (Burke, Hainsworth, Eakes, & Lindgren, 1992; Eakes, 1993; Hainsworth, 1994; Hainsworth, Eakes, & Burke, 1994; Lindgren, 1996). Others have since been validated by the experience of chronic sorrow among those diagnosed with a chronic condition (Isaksson, Gunnarsson, & Ahlström, 2007; Lichtenstein, Laska, & Clair, 2002; Smith, 2009).

The NCRCS also conducted research studies designed to investigate the occurrence of chronic sorrow among individuals who had experienced a single loss event rather than an ongoing loss. Toward the end, people who had experienced the death of a significant other a minimum of 2 years

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prior to the study were interviewed. This time lapse was to allow for acute grief to have subsided. Findings revealed that a vast majority (97%) of those interviewed evidenced chronic sorrow (Eakes, Burke, & Hainsworth, 1999). These findings lead to further modification of the defining characteristics of chronic sorrow, with recognition that it was ongoing disparity associated with the loss, rather than the ongoing nature of the loss experience as originally thought, that was the antecedent to chronic sorrow. Consequently, chronic sorrow was redefined as permanent, periodic recurrence of pervasive sadness or other grief-related feelings associated with ongoing disparity resulting from significant loss (Eakes, Burke, & Hainsworth, 1998). The necessary antecedent event is involvement in an experience of significant loss. This loss may be ongoing in nature with no predictable end, such as with the birth of a disabled child or diagnosis of a debilitating illness, or it may be more circumscribed as with the death of a loved one. Disparity is created by a loss/situation when an individual's current reality differs markedly from the idealized or when a gap exists between the desired and the actual reality. This lack of closure sets the stage for grief to be periodically reexperienced. That is, the chronic sorrow experience is cyclical and continues as long as the disparity created by the loss remains.

Middle Range Nursing Theory of Chronic Sorrow The middle range theory of chronic sorrow (Eakes et al., 1998) was inductively derived and validated through the qualitative studies described above as well as a critical review of existing literature (see Fig. 6.1). Chronic sorrow was reconceptualized based on these findings and is now defined as “the periodic recurrence of permanent, pervasive sadness or other grief-related feelings associated with ongoing disparity resulting from a loss experience” (Eakes et al., 1998, p. 180, 1999). Moreover, chronic sorrow is characterized as pervasive, permanent, periodic, and potentially progressive in nature and continues to be viewed as a normal response to loss. Indeed, the theory of chronic sorrow purports that the periodic return of grief among individuals and caregivers whose anticipated life course has been interrupted continues throughout one's lifetime as long as the disparity created by the loss remains. As stated by

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Patrick-Ott (2011, p. 110), in reference to manifestation of chronic sorrow in parents of disabled children, “Chronic Sorrow is continual as it moves like waves over a sandy shore such that with each newly understood dimension of the child's significant disability and its meaning for the parent's lifelong care-giving role brings a new tide of chronic sorrow.”

Figure 6.1 Theoretical model of chronic sorrow. (From Eakes, G. G., Burke, M. L., & Hainsworth, M. A. (1998). Middle range theory of chronic sorrow. Image: The Journal of Nursing Scholarship, 30(2), 179–184.)

The middle range theory of chronic sorrow provides a framework for understanding the reactions of individuals to various loss situations and offers a new way of viewing the experience of bereavement. Although chronic sorrow is viewed as a normal response to the ongoing disparity or void created by significant loss, it is important to note that normalization

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of the experience in no way diminishes the validity or the intensity of the feelings experienced. At times, feelings can be intense and distressing for the individual experiencing chronic sorrow.

Involvement in an experience of significant loss is the necessary antecedent to the development of chronic sorrow. This may be a loss with no predictable end, such as the birth of a disabled child or diagnosis of a chronic illness, or a more clearly defined loss event such as the death of a loved one. The second antecedent to chronic sorrow is ongoing disparity resulting from the loss. That is, a gap exists between the desired and the actual reality. The lack of closure associated with ongoing disparity sets the stage for chronic sorrow, with the loss experienced in bits and pieces over time. The defining characteristics of chronic sorrow borne out by the research are pervasiveness, permanence, periodicity, and the potential for progressivity. As graphically represented in the theoretical model of chronic sorrow, the experience of chronic sorrow may occur at any point across the life span.

Trigger events, also referenced as milestones, are those situations or circumstances that bring the disparity created by the loss into focus, thereby triggering the grief-related feelings associated with chronic sorrow. Triggers of chronic sorrow have been shown to vary depending on the nature of the loss experience. For affected individuals, chronic sorrow is most commonly triggered when individuals confront disparity with established norms, whether social, development, or personal in nature (Eakes, 1993; Eakes et al., 1993; Hainsworth, 1994; Isaksson & Ahlström, 2008; Isaksson et al., 2007), for example, when someone diagnosed with a chronic illness is unable to engage in an activity that they once enjoyed due to exacerbation of their condition.

The most frequent trigger of chronic sorrow among parents of young children with disabilities is disparity associated with developmental milestones (Bowes et al., 2009; Burke, 1989; Clubb, 1991; Damrosch & Perry, 1989; Fraley, 1986, 1990; George & Vickers, 2006–2007; Golden, 1994; Hobdell, 2004; Hobdell et al., 2007; Hummel & Eastman, 1991; Krafft & Krafft, 1998; Mallow & Bechtel, 1999; Olshansky, 1962; Patrick- Ott & Ladd, 2010; Phillips, 1991; Seideman & Kleine, 1995; Shumaker, 1995; Wikler et al., 1981). The chronic sorrow of other family caregivers is often triggered by crises associated with management of the family member's illness and by recognition of the never-ending nature of the caregiving activities (Bettle & Latimer, 2009; Bowes et al., 2009; Eakes, 1995; Eakes et al., 1993; George & Vickers, 2006–2007; Hainsworth,

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1995; Hainsworth et al., 1995; Isaksson & Ahlström, 2008; Isaksson et al., 2007; Lindgren, 1996; Patrick-Ott & Ladd, 2010).

The chronic sorrow experience of bereaved individuals is triggered by those situations and circumstances that magnify the “presence of the absence” of the deceased, such as anniversaries and other special occasions (Eakes et al., 1998, p. 182). In addition, changes in roles and responsibilities necessitated by the death of a loved one may trigger chronic sorrow.

Another key element of the theoretical model of chronic sorrow is management methods. This term is used to refer to both personal coping strategies used by individuals during the chronic sorrow experience (internal) and supportive interventions provided by helping professionals (external). As depicted in the theoretical model, effective internal and external management methods lead to increased comfort and may serve to extend the time between episodes of chronic sorrow. Figure 6.2 illustrates the progression of chronic sorrow episodes over time.

Figure 6.2 Progression of chronic sorrow episodes over time.

Effective internal management strategies used by those with chronic sorrow are consistent across the various loss situations. Action-oriented strategies that increase feelings of control are most frequently used to cope with the recurrence grief-related feelings of chronic sorrow (Burke, 1989; Eakes, 1993, 1995; Hainsworth, 1995; Hainsworth et al., 1994, 1995; Hobdell et al., 2007; Lindgren, 1996). Examples of action-oriented coping include continuing to pursue involvement in interests and activities, gathering information specific to one's loss experience, and seeking out

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respite opportunities. Other types of coping strategies identified as helpful in dealing with the chronic sorrow experience are labeled as cognitive and interpersonal. Cognitive strategies include adopting a “can do” attitude and focusing on the positive elements of one's life (Burke, 1989; Eakes, 1993, 1995; Hainsworth, 1995; Hainsworth et al., 1994, 1995; (Isaksson & Ahlström, 2008). Interpersonal ways of coping include talking with someone close or a trusted professional and interacting with others in a similar situation such as in a support group (Burke, 1989; Eakes, 1993, 1995; Fraley, 1990; Hainsworth, 1995; Hainsworth et al., 1994, 1995; Wikler et al., 1981).

Interventions provided by health care professionals, referred to as external management methods, must be based upon the premise that chronic sorrow is a normal response to a significant loss situation. As long as disparity created by a loss experience remains, one can anticipate that the individual will likely experience chronic sorrow. Indeed, normalization of the periodic re-grief of chronic sorrow is foundational to all other interventions. It is important for professionals to recognize that individuals who have experienced a significant loss may evidence the periodic recurrence of grief-related feelings defined as chronic sorrow. Armed with this awareness, anticipatory guidance may be provided regarding the situations and circumstances likely to trigger episodes of chronic sorrow. Personal coping mechanisms (internal management methods) can be assessed, strengthened, and supported.

In addition, specific interventions provided by health care professionals, categorized as roles, have been noted as helpful by those experiencing chronic sorrow (Burke, 1989; Copley & Bodensteiner, 1987; Eakes, 1993, 1995; Eakes et al., 1993; Fraley, 1990; Hainsworth, 1995; Hainsworth et al., 1995; Hobdell et al., 2007; Hummel & Eastman, 1991; Isaksson & Ahlström, 2008; Wikler et al., 1981). Family caregivers with chronic sorrow derive the most benefit from professional interventions labeled as the role of “teacher/expert.” More specifically, these actions include providing situation-specific information in a manner that can be easily understood and giving practical tips for managing caregiving responsibilities (Burke, 1989; Clubb, 1991; Eakes, 1995; Fraley, 1990; Hainsworth, 1995; Hainsworth et al., 1995; Hummel & Eastman, 1991; Warda, 1992, Wikler et al., 1981). Actions associated with the professional role of “empathetic presence” characterized by taking time to listen, offering support, focusing on feelings, and recognizing uniqueness of each individual are also helpful to those who were in a caregiver role (Burke,

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1989; Clubb, 1991; Eakes, 1995; Fraley, 1990; George & Vickers, 2006– 2007; Gordon, 2009; Hainsworth, 1995; Hummel & Eastman, 1991; Isaksson & Ahlström, 2008; Olshansky, 1962; Phillips, 1991; Teel, 1991; Warda, 1992).

For those individuals affected with a chronic or life-threatening condition as well as bereaved persons, the professional role of “empathetic presence” discussed above is perceived as most helpful in dealing with the periodic episodes of chronic sorrow. In addition, the complementary role of “caring professional,” evidenced by sensitivity, respectfulness, and nonjudgmental acceptance, and interventions associated with the role of “teacher/expert” are described as beneficial (Burke, 1989; Eakes, 1993; Eakes et al., 1993; Hainsworth et al., 1995, Isaksson & Ahlström, 2008).

Research Applications of Chronic Sorrow Chronic sorrow has research applications among a variety of populations and across a myriad of loss situations. Identification of the presence of chronic sorrow among affected individuals, family caregivers, and bereaved individuals as well as unique situations such as parental rejection secondary to divorce (McAdams, Dewell, & Holman, 2011) can alert professionals to potential triggers of the recurrent grief and lead to the identification and reinforcement of effective coping mechanisms for those experiencing chronic sorrow.

Example Isaksson and Ahlström (2008) utilized the theoretical model of chronic sorrow as a framework for exploring coping strategies of 38 individuals diagnosed with multiple sclerosis. The subjects, identified in an earlier study as experiencing chronic sorrow, were interviewed using the questions on the NCRCS Chronic Sorrow Questionnaire that focused on management strategies. Qualitative content analysis was conducted on verbatim transcripts with identification of both internal and external management methods. Coping strategies were further categorized as

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“effective” or “ineffective.” Findings were consistent with the theoretical model of chronic sorrow,

revealing the use of both internal and external management methods by those experiencing chronic sorrow. Moreover, when effective internal management methods were used, individuals experienced increased comfort; conversely, when episodes of chronic sorrow were not managed effectively, subjects described increased discomfort. Effective internal management methods were captured in the recurring theme of “mastering with realistic awareness” and included distraction, allowing and sharing emotions, having a “can do” attitude, and taking care of oneself. Effective external management methods were categorized under the theme of “endorsing management” represented by a caring and supportive family/friends and confirmation from health care professionals. Ineffective internal coping was described as “struggling with vulnerability,” while ineffective external management was classified under the theme of “deficient affirmation.” These strategies are reflective of those identified in the research underpinning the theoretical model of chronic sorrow.

The researchers concluded that the theoretical model of chronic sorrow provided an empirically trustworthy framework for interpretation of data and was useful in increasing both knowledge and understanding of chronic sorrow.

Other examples of research applications for the Theory of Chronic Sorrow are presented in Table 6.1.

Table 6.1 Examples of Research for Application to Practice

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NCRCS Chronic Sorrow Instrument Development Historically, research on chronic sorrow has employed qualitative methods with open-ended interview guides used in both face-to-face and telephone interviews with study participants. The Burke/NCRCS Chronic Sorrow Questionnaire (Burke, 1989), with versions adapted for individuals affected with chronic conditions, for family caregivers, and for bereaved

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individuals, has been used for the majority of studies documented in the literature. This interview guide is composed of 11 open-ended questions that explore feelings experienced at the time of the loss and whether or not they have been reexperienced. Moreover, questions focus on circumstances or situations that trigger recurrence of the grief-related feeling and identification of effective coping mechanisms.

In 2001, two of the original members of the NCRCS undertook the development of a quantitative assessment tool. Questions for the instrument were developed based on the theoretical model and findings from the qualitative studies previously conducted by members of the NCRCS and other researchers. Face and content validity were established by using Lynn's (1986) methodology for establishing validity of an instrument. Once face and content validity of the Burke/Eakes Chronic Sorrow Assessment Tool were established, test–retest reliability studies were conducted. Subjects participating in this aspect of instrument development represented each of the populations previously studied (family caregivers, affected individuals, and bereaved persons). Test–retest correlations for items 4 through 9 (the first three questions assess demographic data) were at acceptable levels, ranging from 0.72 to 0.93. Questions 10 and 11 allow for little variability in responses, and the restricted response range resulted in more marginal test–retest correlations on these items (0.62 and 0.56, respectively) (see Box 6.1).

BOX 6.1 Burke/Eakes Chronic Sorrow Assessment Tool

The questions below are about the impacts of certain life events or situations on people over a period of time so that helping professionals can better meet their needs. In answering these questions, please focus on the impacts that these life events or situations continue to have on your life. There are no right or wrong answers. You do not have to answer any or all of the questions and can stop without penalty of any kind. Thank you for taking the time to answer these questions.

1. Which of the following best describes your situation? (Please check only one.) a. Parent of disabled child

(please specify the disability) ________________________________________________________________

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b. Person with a chronic condition (please specify the condition) ________________________________________________________________

c. Caregiver of someone with a chronic or life-threatening illness (please specify the condition) ________________________________________________________________

d. Bereaved person (please specify the relationship of deceased to you) ________________________________________________________________

2. I have been dealing with this situation/loss for ______ years (please write in number of years).

3. Please provide the following information about yourself: a. Sex: ______ male ______ female b. Age: ______ years c. Marital status: ______ single ______ married ______ widowed

______ divorced ______ separated d. Religion: ______ Protestant ______ Catholic ______ Jewish

Other (please specify) ______________________________ e. Ethnic origin: ______ Caucasian ______ Hispanic ______

African-American ______ American Indian ______ Asian Other (please specify) ______________________________

f. Please indicate your highest level of education: a. Below high school b. High school graduate c. Associate/technical degree d. Bachelor's degree e. Master's degree f. PhD/MD or equivalent g. Total family income per year from all sources before taxes: a. Below $5,000 b. $5,001–10,000 c. $10,001–15,000 d. $15,001–20,000 e. $20,001–25,000 f. $25,001–30,000 g. $30,001–40,000 h. Over $40,000

4. Even though some time may have passed since you began dealing with your situation/loss, you may still be coping with some ongoing issues and reactions. Please read the following statements and

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indicate if this is true for you. Remember, there are no right or wrong answers.

5. The following are feelings you may have experienced as a result of your situation/loss. At those times, when you experience these feelings associated with your situation/loss, please indicate how upsetting they are for you. Remember, there are no right or wrong answers.

6. The questions below are more about the feelings you may experience related to your situation/loss. Please mark the extent to which each statement below is true for you. In describing my feelings about my situation/loss, I

7. There may be certain times when you tend to experience the feelings associated with your situation/loss. Please read the following statements and indicate which is true for you. These feelings about my situation/loss come up when I:

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8. The statements below are things you may have found helpful to you in managing the feelings associated with your situation/loss. Please indicate which is true for you. It helps me deal with my feelings when I:

9. The following questions are to find out how helping professionals can assist people who are dealing with situations/losses such as yours. Please indicate which is true for you. Remember, there are no right or wrong answers. It helps me deal with my feelings when helping professionals:

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10. Friends and family may also be helpful to you as you deal with the feelings associated with your situation/loss. Please read the following and indicate which is true for you. It helps me deal with my feelings when family and friends: Thank you for answering these questions. Please return the completed questionnaire at this time.

Summary Chronic sorrow has gained increased attention in the past three decades, based in large part on the research endeavors of the NCRCS. In addition, increased awareness of the changing nature of grief associated with significant losses, whether ongoing in nature or single loss events, has spurred interest in this phenomenon. The theory of chronic sorrow provides a framework for understanding

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and working with individuals who have experienced significant loss. Specifically, situations and circumstances that trigger chronic sorrow are identified, and management methods deemed helpful to those experiencing chronic sorrow are described. The theoretical model of chronic sorrow, along with the recently constructed Burke/Eakes Chronic Sorrow Assessment Tool, will facilitate further expansion of research on chronic sorrow and provide opportunities for testing of the theory. While studies have identified presence of chronic sorrow among other cultures (Langridge, 2002; Rungruangkonkit, 2006; Isaksson et al., 2007; Bowes et al., 2009), there remains the need for expanded exploration of cultural variations in the experience of chronic sorrow in future research. In addition, relevance of the theory of chronic sorrow to types of loss experiences such as divorce and abuse needs to be further investigated. The middle range theory of chronic sorrow has widespread application for nurses, social workers, counselors, clergy, and others who strive to better understand individuals' responses to loss and to define effective interventions for those experiencing chronic sorrow. Although chronic sorrow is viewed as a normal response to ongoing disparity resulting from a loss, it is important to note that recognition of the periodic re-grief characteristic of chronic sorrow and provision of supportive interventions can provide an increased level of comfort for those experiencing it. At this stage of theory development, attention needs to be directed to the conduct of studies designed to measure outcomes related to provision of documented “helpful” interventions.

Critical Thinking Exercises

1. You are a case manager for a family with a young child diagnosed with cerebral palsy. Explain how the theory of chronic sorrow can be used as a framework for planning care and identifying resources for this family.

2. Expand the application of the theory of chronic sorrow to a population not yet fully studied. Describe the strengths and weaknesses of the theory in relation to the population identified and discuss if the theoretical premises apply.

3. Draft a research study designed to measure outcomes for the external

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management strategies described in the theory.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Chronic Sorrow.

REFERENCES Bettle, A. M. E., & Latimer, M. A. (2009). Maternal coping and

adaptation: A case study examination of chronic sorrow in caring for an adolescent with a progressive neurodegenerative disease. Canadian Journal of Neuroscience Nursing, 31(4), 15–21.

Bowes, S., Lowes, L., Warner, J., & Gregory, J. W. (2009). Chronic sorrow in parents of children with type 1 diabetes. Journal of Advanced Nursing, 65(5), 992–1000.

Burke, M. L. (1989). Chronic sorrow in mothers of school-age children with a myelomeningocele disability (Doctoral dissertation) Boston University, 1989. Dissertation Abstracts International, 50, 233B–234B.

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7 Spiritual Care in Nursing Practice (SCiNP)

Lisa Burkhart and Nancy S. Hogan

Definition of Key Terms

Patient cue Verbal, nonverbal, or situational sign that a person is in need of spiritual care

Reflection A process of quieting the mind and finding meaning of what happened during a spiritual encounter

Religion A social institution where people can express their spirituality as part of an organized belief system

Religiosity The human expression of rites and rituals of a faith tradition

Spirit Individually defined as that aspect of person that differentiates humans from other living things

Spiritual care A purposeful process of helping another find meaning and purpose in life through a mutual connection

Spiritual intervention Actualizing spiritual care by promoting patient self-reflection, promoting connectedness between patient and

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family, and promoting patient connectedness with a Higher Power/God

Spirituality The expression of meaning and purpose in life

Spiritual well-being A deeper wisdom and peace found through a process of finding meaning and purpose in life

Introduction Spirituality has been a foundational and central dimension of nursing practice, beginning with the Catholic religious orders of the Middle Ages and Florence Nightingale (Nightingale, 1994; O'Brien, 2014; Pesut, 2006; Pesut & Thorne, 2007). Spirituality and spiritual care have recently reemerged over the past several decades as important phenomena within nursing research, standards of practice, and education. Research has demonstrated that spirituality is associated with better physical, psychological, and social dimensions of health, which led to a Joint Commission standard that requires the provision of spiritual care in hospitals, particularly to patients at end of life (Clark, Drain, & Malone, 2003; Joint Commission on Accreditation of Healthcare Organizations, 2003). The American Nurses Association also requires the provision of spiritual care in the Scope and Standards of Nursing Practice (2010a), Social Policy Statement (2010b), and Code of Ethics (2015), and the AACN incorporates spiritual care in the Essentials of Baccalaureate Education (American Academy of Colleges of Nursing, 2009).

The majority of spirituality and spiritual care theories provide a metaphysical and philosophical accounting of spirituality, along with guidelines in providing spiritual care (Reed, 1991; Watson, 2005). The Spiritual Care in Nursing Practice (SCiNP) theory is a middle range theory focused on spiritual care encounters.

Historical Background Spirituality has existed since the beginning of human kind and is grounded

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in the philosophical question, “What does it mean to be a human being?” Philosophers have different accountings for what is a human being, but the constant thread across philosophers is that humans have a unique dimension of self, called the spirit, and the expression of that spirit, or spirituality, is the exploration of meaning and purpose in life. For example, a human being could be viewed as the way our body or cellular structure is organized (Aristotle, 1976), a unified separate entity within the body (Plato/Socrates, 1997), an evolution of spiritual being (Aquinas, 1949), our individuality with free choice (Kierkegaard, 1989), or a form of evolving energy through space and time that connects us to each other and God (Teilhard de Chardin, 1960a,b). Regardless of how one defines the spirit, the work of “the spirit” is to search for meaning and purpose in life and to transcend who one is today toward who one can become in the future. This process of exploration occurs through self-reflection, relationships with other people, and experiencing literature and the arts. Humans also find meaning and purpose in life through connections with nature and a Higher Power, or God.

Spiritual care in Western nursing emerged in the Middle Ages from the Catholic religious orders as a calling from God in Christ's healing ministry (O'Brien, 2014). Nightingale (1994) and Nightingale (1860/1969) recognized spirituality and spiritual care as central to nursing practice and nursing research. Nightingale believed that there was an omnipotent God, which was the source of all Truth: “A Law is nothing else than a Thought of God” (Nightingale, 1994, p. 35). It was nurses' role to uncover that Truth through research to learn God's Will and, in practice, to eliminate barriers in the environment so that God could do His Will (Nightingale, 1994). This applied to both specific patient care situations and the development of health care policy (Nightingale/McDonald, 2003).

This conceptualization is consistent with other nursing theories. Watson developed a grand theory of spirituality and focused on the nurse– patient relationship incorporating a metaphysical transpersonal dimension of caring. Her theory also presented 10 Carative Factors to guide practice (Watson, 1999, 2005). Pamela Reed was one of the first nurse researchers to define spirituality in nursing as the process of finding meaning and purpose in life through connectedness with self, others/environment, and/or a power greater than oneself across time (Reed, 1987, 1991). For example, some individuals experience spirituality internally through self- reflection, transpersonally in close relationships, and/or transcendentally with a Higher Power. This lead to her theory of self-transcendence (Reed,

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1991). More recently, spiritual care has been recognized as an essential

component of nursing care in the United States and is a requirement in nursing practice and education (ref). Providing spiritual care is a health care requirement and is recognized in the international health care data base infrastructure, called the Systematized Nomenclature of Medicine (SNOMED CT) (www.nlm.nih.gov/research/umls/snomed/snomed_main.html).

Empirical Development of the Spiritual Care in Nursing Practice Theory The reemergence of spiritual care as essential to quality health care demanded the evidence to guide evidence-based spiritual care practice. Early in 2005, the literature converged on a definition of spirituality and the association of spiritual well-being on patient health, but there was no empirically derived theory of spiritual care in nursing practice.

Burkhart and Hogan (2008) first discovered the SCiNP theory through a grounded theory study using classic Glaserian methods (Glaser, 2001; Glaser & Strauss, 1967). Twenty-five nurse participants who worked across the continuum of care attended one of four focus groups. Theoretical sampling required an additional focus group of nine nurse managers. Findings revealed a purposeful process following seven categorical phases and related subcategories or subprocesses, as shown in Figure 7.1.

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http://www.nlm.nih.gov/research/umls/snomed/snomed_main.html

Figure 7.1 Spiritual care in nursing practice theoretical framework. (Reprinted with permission from Burkhart, L., & Hogan, N. (2008). An experiential theory of spiritual care in nursing practice. Qualitative Health Research, 18(7), 928–938.)

The categories are cue from patient, decision to engage or not engage in spiritual encounter, spiritual care intervention, immediate emotional response, searching for meaning in encounter, formation of spiritual memory, and nurse spiritual well-being. This is a process whereby positive nurse–patient spiritual encounters can lead to positive spiritually growth- filled memories that will increase nurses' spiritual well-being. In contrast, spiritually distressing nurse–patient spiritual encounters can lead to negative, spiritually distress-filled memories that can decrease the nurses' spiritual well-being. However, spiritual distressing encounters can lead to positive, growth-filled memories with reflection. This search for meaning is integral in forming the growth-filled memory. Meaning-filled memories of spiritual encounters lead to greater nurse spiritual well-being. A stronger spiritual well-being supports the nurse's ability to recognize a patient's need for spiritual care in the future (Burkhart & Hogan, 2008).

Definition of Theory Concepts Each concept in the theory is defined as follows.

Patient Cue Spiritual care happens in the moment when the patient expresses a need for

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spiritual care. Therefore, the first concept in the theory is recognizing the cue, as well as experiencing a patient's openness to engage spiritually. Cues can be verbal (Why is this happening to me? Is God punishing me?), nonverbal (crying, whining, demanding behavior), or situational (receiving a poor prognosis, end of life, learning of life-threatening treatments).

Decision to Engage/Not Engage When the nurse recognizes a patient cue, the nurse consciously chooses to engage or not engage in spiritual care. Reasons to not engage include no perceived time, no collegial or institutional support for providing spiritual care, or personal spiritual exhaustion. If the nurse chooses not to engage, spiritual care does not happen.

Spiritual Intervention If nurses choose to engage, nurses enter the next phase in the theory of performing spiritual interventions. This third phase is when spiritual care is actualized. Both the patient and nurse spiritually connect and the nurse engages in one of three types of interventions: promoting patient self- reflection, promoting connectedness between patient and family, and promoting patient connectedness with a Higher Power/God. Promoting patient self-reflection involves discussions that promote the patients' understanding of the meaning in their illness experience. At times, patients are searching for answers to life questions and the meaning of their life experiences. Nurses facilitate that exploration. Promoting connectedness between patient and family involves actions that eliminate barriers and help maintain a spiritual closeness with loved ones. Promoting patient– family connectedness occurs in many ways and is contingent on patient and family needs. The nurse assesses those needs and individualizes the care to promote meaningful relationships based on that recognized need. Nurses also facilitate patients' connection to a Higher Power, when appropriate. Many patients find meaning by gaining connectedness with God in two ways: by facilitating adherence to religious rites and rituals and through prayer. Facilitating religious rituals requires the nurse to assess religious needs and meet those needs. Nurses also promote spiritual connectedness with God through prayer either by praying themselves or by initiating a chaplain referral.

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Immediate Emotional Response (Positive/Negative) By definition, spiritual encounters are meaningful. Nurses are experiencing mortality, life-changing, and deeply meaningful expressions of love, hope, and, at times, pain. These experiences affect the nurse and lead to either a positive or a negative emotional response. Nurses can leave a spiritual encounter crying, depleted, happy, and/or fulfilled, depending on the nature of the encounter.

Search for Meaning The emotional release leads to a process of searching for meaning in the encounter. This is a time of finding deeper meaning in those spiritual experiences. Nurses engage in their own spiritual activities, which include reflecting with self, reflecting with others, and faith rituals. Self-reflection is a process of quieting the mind and exploring the meaning of what happened during the spiritual encounter. This typically occurs when driving home, in the shower, gardening, and/or at bedtime. Nurses also reflect with others, typically with individuals who have had similar spiritual experiences. These individuals include other nurses and chaplains. Many times, family and friends cannot or do not assist in this process because they cannot relate to that nursing spiritual encounter experience. Faith traditions can also provide an opportunity to search for spiritual meaning by attending religious services, reading religious/spiritual materials, and/or praying.

Formation of a Spiritual Memory This reflective process leads to a memory that stays with the nurse. For many, the memory is so clear; it seems as if it happened recently. These spiritual memories come together to form a cohesive understanding of life experiences. There are three pathways toward the spiritual memory. The degree and type of spiritual reflection that occurs during the “search for meaning phase” lead to different spiritual memories. Positive emotions following a spiritual encounter and meaningful reflection lead to growth-

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filled spiritual memories and reinforce the joy of nursing practice. A spiritual encounter with a negative emotional response and minimal or negative reflective activities leads to a spiritually distressing memory. However, a spiritual encounter with negative emotions and meaningful reflective activities can lead to a spiritually growth-filled memory. This latter path leads to a deeper wisdom, peace, and feeling privileged in participating in these meaningful experiences. The type of reflective activity affects the memory and cohesive understanding of life experiences.

Spiritual Well-Being Spiritual wisdom is the degree of wisdom through this process of finding meaning and purpose in spiritual encounters. This spiritual wisdom can provide strength and insight to support the ability to provide spiritual care to others.

The process of providing spiritual care and finding meaning in spiritual encounters can help the nurse promote his or her own spiritual well-being and can affect whether the nurse decides to engage in spiritual care in the future. Subsequent research was needed to further develop and test the veracity of the theory.

Instruments Used in Empirical Testing This phase of theory verification focused on developing an instrument generated from the grounded theory data, representing each of the categories of the theory (Burkhart, Schmidt, & Hogan, 2011). Initially, 48 items were chosen to represent the seven categories for the instrument development study. To test this initial pool of items, a convenience sample of 298 adult and pediatric acute care, ambulatory, home health, hospice staff and rehab nurses at two hospitals (n = 248) and graduate students at a school of nursing (n = 50) completed the instrument. Factor analysis yielded a 17-item tool measuring three of the concepts in the theory: spiritual intervention (4 items), meaning-making reflective practice (10

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items), and faith ritual reflective practice (3 items). Recognizing the patient cue and decision to engage in a spiritual encounter was assumed to have occurred prior to the spiritual care intervention. Also, the search for meaning did not factor separately from the spiritual memory, as the survey ultimately measured the memory post–spiritual encounter. Table 7.1 presents this instrument as well as other selected tools that measure spiritual concepts.

Table 7.1 Selected Instruments

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Application of the Theory in Practice The theory revealed three clinical applications to spiritual care:

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recognizing the patient cue, providing spiritual interventions, and nurse reflective practices. These three components of spiritual care were integrated into an educational pedagogy as part of a senior capstone clinical practicum. This pedagogy included both face-to-face retreats and an online discussion board (Burkhart & Schmidt, 2012). The effectiveness of this program was measured in an RCT pre-/posttest 2 by 2 design with senior nursing students during their capstone clinical immersion course (n = 59). Findings revealed a statistically significant increase in students' perceived ability in providing spiritual care, particularly in complex family clinical situations. Findings also indicated a significant increase in the student's use of reflective practices, which students found to help support them during stressful times.

Several international quantitative and qualitative research studies used the SCiNP theory as a conceptual framework (Parsian & Dunning, 2009) or definition of spiritual care (Carr, 2010; Fouka, Plakas, Taket, Boudioni, & Dandoulakis, 2012; Granero-Molina et al., 2014; Koren & Papamiditriou, 2013; Koren et al., 2009; Turan & Karamanoglu, 2012) in the theoretical framework or philosophical underpinnings for their studies.

The SCiNP theory provides the theoretical framework for spiritual care at Loyola University Health System. The electronic health record, using Epic, incorporates a spiritual assessment using a 5-point Likert scale of a patient's initial spiritual need, with “1” as severely compromised and “5” as not compromised. This patient cue recognition is part of the daily documentation flow sheets as a common row for both nursing and chaplain documentation (Burkhart, 2009, 2011; Burkhart & Androwich, 2009). This uses informatics to ease the decision to engage in spiritual care by quickly informing others of this need (minimizing the time constraint and supporting the institutional mission of providing spiritual care) and automatically triggers a chaplain referral to promote an interprofessional response to the patient's spiritual needs.

The chaplain also is available to assist the nurse in reflection post– spiritual encounter if needed (thereby promoting the nurses' meaning- making process). In this model, patients with a “1” or “2” level of spirituality are considered in spiritual distress. This numeric measurement system tabulates the number of patients with spiritual needs in monthly reports based on unit, specialty, or time of day, thereby assisting management in anticipating patient spiritual needs for chaplain staffing. Since Loyola University Health System was one of the early adopters of Epic, this feature is now part of the product and available for other Epic

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users. Other examples of spiritual care practices and issues consistent with

the theory are found in Table 7.2 with an example of implementing a program to promote spiritual care described in some detail in Using Middle Range Theory in Practice 7.1.

Table 7.2 Examples of Theory in Practice

USING MIDDLE RANGE THEORY IN PRACTICE 7.1

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Source: Smith, T., & Gordon, T. (2009). Developing spiritual and religious care competencies in practice: Pilot of a Marie Curie blended learning event. International Journal of Palliative Care, 15(2), 86–92.

Problem Though it is recognized within the profession that holism, which

integrates mind, body, and spirituality, is necessary for quality nursing care, “many professionals report barriers to addressing spiritual issues in practice which inhibits the implementation of theory into practice” (p. 86).

Nursing Intervention The Marie Curie Cancer Care Spiritual and Religious Care

Competencies for Specialist Palliative Care was used to develop a pilot learning event focusing on the development of spiritual care competencies. As part of the planning process, three focus groups were held, attended by registered nurses, hospice volunteers, and health care assistants. The purpose of the groups was identification of the focus and level of the content to be included in the proposed course. Four main themes emerged: self-awareness, communication skills, theoretical knowledge, and professional role.

The course was delivered in a blended learning model with both face-to-face and Internet learning experiences. An online learning development team helped to determine the scope of the content and timing of the learning event. Online learning activities focused on the identified themes, and the online portion of the course was offered over a 5-week period. To complete the course, it required 30 to 60 minutes on a weekly basis. On week 6, a study day was offered, and on week 7, follow-up activities focused on final reflections. Facilitators moderated each activity and encouraged and summarized discussions. Technical problems were addressed by the online learning technologist.

Twelve participants were recruited, and six completed the program. Evaluation of the program from both facilitator and participants revealed that “participants appeared more open to explorations of their own issues and spiritual beliefs, more confident in sharing with each other, and more willing and able to understand their own and others' spiritual needs” (p. 92). The program was considered a success and was placed in a portfolio of learning events that are available on a nationwide basis.

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Application of the Theory in Research This fairly recently developed theory has yet to be tested by research. There is a body of research that explores issues relevant to the theory and supports the major concepts of the theory. Not surprisingly, review of the published research does not reveal any that were identified as randomized control studies (RCTs). The research often involved the use of surveys to provide for descriptions or, in some instances, correlations. Using Middle Range Theory in Research 7.2 provides an example of the use of a survey to better describe nurses' attitudes toward providing spiritual care, correlating them with demographic data. In Using Middle Range Theory in Research 7.3, there is an example of a survey used with qualitative analyses of data to also consider nurses' perceptions of spirituality and spiritual care.

USING MIDDLE RANGE THEORY IN RESEARCH 7.2

Nursing has as an aim providing holistic care to patients. The domain of spirituality is seen as the most often neglected domain in daily nursing practice.

Source: Chan, M. F. (2009). Factors affecting nursing staff in practicing spiritual care. Journal of Clinical Nursing, 19, 2128–2136. doi: 10.1111/j.1365-2702.2008.02690.x

Purpose/Research Question This study had two focuses: (1) an examination of nurses' attitudes

to practicing spiritual care and (2) the determination of factors associated with nurses' attitudes to practicing spiritual care.

Research Design

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The design was correlational and retrospective.

Sample/Participants The convenience sample was comprised of all nurses working in a

Chinese hospital in 2006, with a total of 178 questionnaires distributed. There was a response rate of 61.7%, a total of 110 questionnaires completed and returned.

Data Collection An instrument was developed for this study. It was based on an

intensive review of the literature and two previously developed instruments. Ten items were identified and submitted to a panel of experts. The content validity index was 0.92 and confirmation factor analysis established construct validity. Test–retest reliability was also 0.92. Internal consistency of the three subscales, nurses' perceptions, practices, and spiritual care practices, had Cronbach alpha scores of 0.83, 0.82, and 0.84, respectively. In addition to the instrument, demographic data were collected.

The questionnaires were distributed to nurses by their ward managers with mechanisms for maintaining confidentiality established. Questionnaires were returned via a secure box and were collected 1 week after distribution. “To examine which variables contributed to the practice scores, bivariate analysis including independent t-test and analysis of variance were used to examine difference and Spearman's rho coefficient correlation was used to quantify the relationships between nurses' perceptions and practice level of spiritual care” (p. 2132).

Findings The analyses of data revealed that those who were married,

previously hospitalized, and employed in the obstetrical and gynecological departments were more likely to have religious beliefs. This group also had higher perception levels of spiritual care and was more likely to be practicing spiritual care.

USING MIDDLE RANGE THEORY IN

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RESEARCH 7.3

Providing spiritual care to patients is a professional nursing responsibility, yet there persists a reluctance to engage in this practice.

Source: McSherry, W., & Jamieson, S. (2013). The qualitative findings from an online survey investigating nurses' perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 22, 3170–3182. doi: 10.1111/jocn.12411

Purpose/Research Question This study had as its stated purpose providing nurses with an

opportunity to express their understandings of spirituality and spiritual care. There were three questions:

1. What do the United Kingdom's Royal College of Nurses (RCN) members understand by the terms spirituality and spiritual care?

2. Do RCN members consider spirituality to be a legitimate area of nursing practice?

3. Do RCN members feel that they receive sufficient support and guidance in these matters?

Research Design The study was descriptive, using a cross-sectional design.

Sample/Participants The research was conducted with the population of members of the

RCN, nurses, midwives, health care support workers, and students. All 410,000+ members were invited to participate in the study. Only 4,054 members completed the survey, a response rate of slightly less than 1.0%. Though this is an obviously low response rate, it is the largest body of knowledge about nurses' perceptions of spirituality and spiritual care in the United Kingdom.

Data Collection This online survey was adapted from an unpublished questionnaire

developed by a graduate student as part of the students Master of Philosophy thesis. It consists of five parts: (1) Spirituality and Spiritual Care Rating Scale, (2) nursing practice, (3) actions, (4) demographics,

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and (5) response box. The questionnaire was reviewed by a panel of experts to determine content validity. It was piloted with RCN members to establish reliability.

Members received notification of the survey through a bulk e-mail, and in the message, they were directed to the organization's website homepage. This site provided a direct link to the survey.

Data were collated using the ProQuest®platform, and a keyword analysis was completed.

Findings Five content themes emerged from the data analysis:

1. Theoretical and conceptual understanding of spirituality. These included finding meaning and purpose in the midst of life's vicissitudes and living with inner peace and calm. Little mention was made of suffering or evil and its relationship to spirituality.

2. Fundamental aspects of nursing. Spirituality was described as essential to the quality of nursing care delivered.

3. Notion of integration and integrated care. Spirituality was considered something that is integrated into care—it should not be considered an “add on.”

4. Education and professional development. Diversity in opinion was expressed with some supporting formal inclusion of spiritual care instruction into nursing programs and others believing that it would be too restrictive with the possibility of unfound assumptions being made by nurses.

5. Religious belief and professional practice. The responses were consistent with the majority of the respondents identifying themselves as Christian. The need for spiritual care practices, with a recognition of the importance for tolerance to diverse beliefs, was expressed. Professional organizations should be helping nurses become more comfortable with providing this type of care.

Meehan (2012) engaged in a consideration of spirituality in nursing from the perspectives of history, Careful Nursing philosophy, and the professional practice model. They, not surprisingly, concluded that spirituality has been integrated with nursing and health throughout history. They found that spirituality in nursing is expressed through actions

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characterized by maintaining human dignity, kindness, compassion, calmness, and tenderness. These qualities ideally involve both caring for self and one another.

Cockell and McSherry (2012) reviewed published research on spiritual care, 2006 through 2010. They found 143 articles, describing studies in 23 countries with the United States accounting for approximately half of the studies. Of those 143 studies, 80 were focused on practitioner and 63 on patients. In summarizing their review of the literature that focused on practitioners, they provided a list of recommendations for nurse managers. For example, they can assess the level of spiritual care provided on their unit, review the support that nurses receive, and promote “an organizational culture that takes spirituality seriously, giving nurses time, encouragement and support in giving spiritual care to patients” (p. 966).

Summary Spiritual care is essential to nursing practice and endorsed by the ANA Scope and Standards of Nursing Practice, Social Policy Statement, and Code of Ethics, and it is incorporated in the AACN Essentials of Baccalaureate Education and is a Joint Commission requirement. The availability of an empirically generated theory guides SCiNP. An empirically derived instrument to measure practice facilitates research in spiritual care. A theoretically derived educational pedagogy meets the AACN requirement for spiritual care education. Spiritual care affects both the patient and the nurse. Searching for meaning through reflective practice promotes spiritual well-being.

Critical Thinking Exercises

1. Draw a picture of what spirituality means to you. Compare your picture with the different philosophical perspectives of spirituality, and evaluate your own perspective of spirituality.

2. Consider how your view of spirituality is lived out in your nursing practice. How do you identify yourself as a nurse?

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3. Think of a time when you provided spiritual care. Consider the phases of the theory and how you were affected by the spiritual encounter. What limits your engagement in spiritual care?

4. In what spiritual practices do you engage? Consider what you do after practicing as a nurse. How do your spiritual practices affect your nursing care?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory, Spiritual Care in Nursing (SCiNP).

REFERENCES American Academy of Colleges of Nursing. (2009). Essentials of

baccalaureate education for professional nursing practice. Washington, DC: AACN.

American Nurses Association. (2010a). Nursing: Scope and standards of practice. Washington, DC: Author.

American Nurses Association. (2010b). Nursing's social policy statement (2nd ed.). Washington, DC: Author.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

Aquinas. (1949). In M. FitzPatrick (trans.). On Spiritual Creatures, Q. 1, Art. 1-2. Milwaukee, WI: Marquette University Press.

Aristotle. (1976). In R. D. Hicks (trans.). De Anima. Cambridge, UK: University Press.

Burkhart, L. (2009). Informatics: Capturing and measuring spiritual care. Vision, 19(4), 16–18.

Burkhart, L. (2011). Documenting the story: Communication within a healthcare team. Vision, 21(3), 28–33.

Burkhart, L., & Androwich I. (2009). Measuring spiritual care with informatics. Advances in Nursing Science, 32(3), 200–210.

Burkhart, L., & Hogan, N. (2008). An experiential theory of spiritual care in nursing practice. Qualitative Health Research, 18(7), 928–938.

Burkhart L., & Schmidt W. (2012). Measuring effectiveness of a spiritual care pedagogy in nursing education. Journal of Professional Nursing,

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28(5), 315–321. Burkhart, L., Schmidt, L., & Hogan, N. (2011). Development and

psychometric testing of the spiritual care inventory instrument. Journal of Advanced Nursing, 67(11), 2463–2472.

Carr, T. J. (2010). Facing existential realities: Exploring barriers and challenges to spiritual nursing care. Qualitative Health Research, 20(10), 1379–1392. doi: 10.1177/1049732310372377

Clark, P. A., Drain, M., & Malone, M. P. (2003). Addressing patients' emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29(12), 659–670.

Cockell, N., & McSherry, W. (2012). Spiritual care in nursing: An overview of published international research. Journal of Nursing Management, 20, 958–969. doi: 10.1111/j. 1365-2834.2012.01450.x

Daaleman, T., & Frey, B. (2004). The spirituality index of well-being: A new instrument for health-related quality-of-life research. Annals of Family Medicine, 2(5), 499–503.

Ellison, C. W. (1983). Spiritual well-being: Conceptualization and measurement. Journal of Psychology and Theology, 11, 330–340.

Fouka, G., Plakas, S., Taket, A., Boudioni, M., & Dandoulakis, M. (2012). Health-related religious rituals of the Green Orthodox Church: Their uptake and meanings. Journal of Nursing Management, 20, 1058–1068. doi: 10.1111/jonm.12024

Glaser, B. G. (2001). The grounded theory perspective: Conceptualizations contrasted with description. Mill Valley, CA: Sociology Press.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York, NY: Aldine.

Granero-Molina, J., Diaz Cortes, M. M., Marquez Membrive, J., Castro- Sanchez, A. M., Lopen Entrambasaguas, O. M., & Fernandez Sola, C. (2014). Religious faith in coping with terminal cancer: What is the nursing experience? European Journal of Cancer Care, 23, 300–309. doi: 10.1111/ecc.12150

Joint Commission on Accreditation of Healthcare Organizations. (2003). Joint commission resources: 2003 comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Author.

Kierkegaard S. (1989). In A. Hannay, (Ed.). Sickness unto death. New York, NY: Penguin.

Koren, M. E., Czurylo, K., Epsom, R., Gattuso, M., Stark, B., Zastrow, P., & Basu, S. (2009). Nurses' work environment and spirituality: A

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descriptive study. International Journal of Caring Sciences, 2(3), 118–125.

Koren, M. E., & Papamiditriou, C. (2013). Spirituality of staff nurses: Application of modeling and role modeling theory. Holistic Nursing Practice, 27(1), 37–44.

Meehan, T. C. (2012). Spirituality and spiritual care from a Careful Nursing perspective. Journal of Nursing Management, 20, 990–1001. doi: 10.1111/j.1365-2834.2012.01462.x

Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing outcomes classification (NOC): Measurement of health outcomes (5th ed.). St. Louis, MO: Elsevier.

Nightingale, F. (1860/1969). Notes on nursing. What it is and what it is not. New York, NY: Dover Publications.

Nightingale, F. (1994). In M. D. Calabria & J. A. Macrae (Eds.). Suggestions for thought. Philadelphia, PA: University of Pennsylvania Press.

Nightingale, F. (2003). In L. McDonald (Ed.). Florence Nightingale on society and politics, philosophy, science, education and literature. Waterloo, ON: Wilfrid Laurier University Press.

O'Brien, M. E. (2014). Spirituality in nursing: Standing on holy ground (5th ed.). Boston, MA: Jones and Bartlett.

Paloutziam, R. F. & Ellison, C. W. (1991). Manual for spiritual well-being scale. New York, NY: Life Advance.

Parsian, N., & Dunning, T. (2009). Spirituality and coping in young adults with diabetes: A cross-sectional study. European Diabetes Nursing, 6(3), 100–104.

Peterman, A. H., Fitchett, G., Brady, M., Hernandez, L., & Cella, D. (2002). Measuring spiritual well-being in people with cancer: The functional assessment of chronic illness therapy—Spiritual well-being scale (FACIT-Sp). Annals of Behavioral Medicine, 24(1), 49–58.

Pesut, B. (2006). Fundamental or foundational obligation? Problematizing the ethical call to spiritual care in nursing. Advances in Nursing Science, 29(2), 125–133.

Pesut, B., & Thorne, S. (2007). From private to public: Negotiating professional and personal identities in spiritual care. Journal of Advanced Nursing, 58, 396–403.

Plato. (1997). In G. M. A. Grube (Ed.). Phaedo. Indianapolis, IN: Hackett. Reed, P. (1987). Spirituality and well-being in terminally ill hospitalized

adults. Research in Nursing and Health, 10, 335–344. Reed, P. G. (1991). Toward a nursing theory of self-transcendence:

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Deductive reformulation using developmental theories. Advances in Nursing Science, 13(4), 64–77.

Taylor, E., Highfield, M., & Amenta, M. (1999). Predictors of oncology and hospice nurses' spiritual care perspectives and practices. Applied Nursing Research, 12(1), 30–37.

Teilhard de Chardin, P. (1960a). The phenomenon of man. London, UK: Collins.

Teilhard de Chardin, P. (1960b). The divine milieu. London, UK: Collins. Turan, T., & Karamanoglu, A. Y. (2012). Determining intensive care unit

nurses' perceptions and practice level of spiritual care in Turkey. Nursing in Critical Care, 18(2), 70–78. doi: 10.1111/j.1478- 5153.2012.00538.x

Watson, J. (1999). Human science and human care: A theory of nursing. Boston, MA: Jones and Bartlett.

Watson, J. (2005). Caring science as sacred science. Philadelphia, PA: Davis.

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PART IV Middle Range Theories: Social

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8 Social Support Marjorie A. Schaffer

Definition of Key Terms

Appraisal support Affirmation from statements or actions made by another (Kahn & Antonucci, 1980)

Emotional support Experience of feeling liked, admired, respected, or loved (Norbeck, Lindsey, & Carrieri, 1981)

Formal support Help from professionals, paraprofessionals, or other service providers from structured community organizations (may be paid or unpaid assistance)

Informal support Help provided through a person's “lay” social network, such as from family members and friends

Informational support Knowledge provided to another during a time of stress that assists in problem solving (House, 1981)

Instrumental support Tangible aid, goods, or services (House, 1981)

Negative support Interactions that cause stress or are more demanding than helpful (Coyne & DeLongis, 1986)

Perceived support Generalized appraisal that individuals are cared for and valued, have others available to them, and are satisfied with relationships (Heller, Swindle, & Dusenbury, 1986)

Social network Structure of the interactive process of persons

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who give and receive help and protection (Langford, Bowsher, Maloney, & Lillis, 1997)

Social support (1) “Aid and assistance exchanged through social relationships and interpersonal transactions” (Fleury, Keller, & Perez, 2009, p. 12); (2) “A well-intentioned action that is given willingly to a person with whom there is a personal relationship and that produces an immediate or delayed positive response in the recipient” (Hupcey, 1998b, p. 313)

Introduction Social support is a middle range theory that addresses structure and interaction in relationships. Social support impacts health status, health behavior, and use of health services (Stewart, 1993). As health professionals, nurses often have access to clients' social networks. Through communication with clients and their family members, nurses can intervene to promote or strengthen social support. The literature identifies many positive consequences of social support, including health-promoting behaviors, personal competence, coping, a sense of well-being, self-worth, and decreased anxiety and depression (Langford et al., 1997). Social support is viewed as a protective factor that contributes to reduced mortality, disease, and disability (Waterworth, Rosenberg, Braham, Pescud, & Dimmock, 2014). Research on social support interventions can provide nurses with knowledge about the most effective strategies for strengthening social support for clients, which contributes to improved health status.

Historical Background Cassel (1974), one of the early social support theorists, introduced the term “social support.” Based on animal studies, he theorized that strengthening social supports could improve the health of humans. Studies in the early 1970s suggested that social support mediates the negative effects of stress (Roberts, 1984). The “buffer” theory and attachment theory have been the

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basis for considerable research on the relationship of social support and health (Callaghan & Morrissey, 1993). The buffer theory suggests that social support protects persons from life stressors (Cassel, 1976; Cobb, 1976). The attachment theory holds that the ability to form socially supportive relationships is related to the secure attachments formed in childhood (Bowlby, 1971). In the mid-1970s to early 1980s, the literature most often described social support in concrete terms, such as an interaction, person, or relationship (Veiel & Baumann, 1992).

In recent years, the term has been used more abstractly, to include perceptions, quality and quantity of support, behaviors, and social systems. Concepts such as social inclusion and social capital have been introduced to expand the importance of community and society as contributors to social support (Jang & Canada, 2014; Wright & Stickely, 2013). The analysis and testing of social support theory has gained multidisciplinary interest and is prominent in nursing and social–psychological literature. Most recently, online social support interventions have been evaluated for effectiveness in strengthening social support. Examples include online support for parents, an online forum for fathers, social support provided through an Internet weight loss community, online perinatal loss support, and a men's online eating disorder forum (Ericsson & Salzmann-Erickson, 2012; Flynn & Stan, 2012; Holtslander, Kornder, Letourneau, Turner, & Paterson, 2012; Hwang et al., 2010; Merkel & Wright, 2012; Patterson, Brewer, & Stamler, 2013; Pector, 2012).

Definition of Theory Concepts Developers of social support theory have organized definitions of social support by a variety of component labels: aspects, categories, constructs, defining attributes, dimensions, interpersonal transactions, subconcepts, taxonomies, and types as shown in Table 8.1. The variety of definitions of social support provided by theorists illustrates the lack of consensus about the nature of social support. This lack of consensus contributes to complexity in evaluating social support interventions and outcomes, comparing research findings, and developing social support theory.

Table 8.1 Theoretical Multidimensional Definitions of Social Support

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Although multidimensional definitions predominate, positive interaction or helpful behavior is shared by all social support definitions (Rook & Dooley, 1985). In addition, most social support theories have the assumption that support is given and received by members of a social network, leading to social integration or a feeling of belonging (Diamond, 1985; Norbeck & Tilden, 1988). Recipients perceive that social support facilitates coping with stressors in their lives (Pierce, Sarason, & Sarason, 1990); high levels of stress may be mediated by social support (Chou, Avant, Kuo, & Fetzer, 2008). Social support is defined as “aid and assistance exchanged through social relationships and interpersonal transactions” (Fleury et al., 2009, p. 12). Social support can be structural,

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focusing on who provides the support, or functional, emphasizing the act of providing social support activities (Callaghan & Morrissey, 1993; Norwood, 1996). In addition, there are many characteristics that influence the quality and adequacy of social support, such as the stability, direction, and source of support (Stewart, 1989a). Social networks can be described by the number and categories of persons who provide social support: family members, close friends, neighbors, coworkers, and professionals (Tardy, 1985). Hupcey (1998a) suggested that a personal relationship is required for social support to take place, defining social support as “a well- intentioned action that is given willingly to a person with whom there is a personal relationship and that produces an immediate or delayed positive response in the recipient”(Hupcey, 1998b, p. 313).

Emotional, Informational, Instrumental, and Appraisal Support The four theoretical constructs or defining attributes of the theory include emotional, informational, instrumental, and appraisal support (Barrera 1986; Fleury et al., 2009; House, 1981; Tilden & Weinert, 1987). Emotional support involves the experience of feeling liked, admired, respected, or loved. Instrumental support is the provision of tangible aid, goods, or services. Informational support refers to providing information during a time of stress. Appraisal support affirms one's actions or statements (House, 1981; Kahn & Antonucci, 1980; Norbeck, 1981).

Negative Social Support It is possible for social support to negatively affect one's well-being (Revenson, Schiaffino, Majerovitz, & Gibofsky, 1991). The perception of or the satisfaction with the support one receives (perceived support) is likely to influence the outcome of the support activity (Heller et al., 1986). The support activity could actually be unrecognized or perceived negatively by the recipient. Negative social support is perceived as unhelpful and may undermine self-esteem. Characteristics of negative social support include stressful or conflicted social networks; misguided or absent support; inappropriate advice; avoidance; disagreement; violations of relationship norms that are interpreted as unpleasant, unwanted, or

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insensitive; and not receiving expected social support (Brooks & Dunkel- Schetter, 2011; Rook, 2014; Stewart, 1993). In addition, costs to the provider of social support such as overload, overcommitment, and stressful emotional involvement may occur (Coyne & DeLongis, 1986; La Gaipa, 1990). The balance of rewards and costs is likely to influence both perceptions and effects of social support. Cost, conflict, reciprocity, and equity are subdimensions that could be measured to capture the negative aspects of social support (Tilden & Galyen, 1987). Assessing the quality of the social support is important. Research shows there's a negative relationship between the quality of social support and caregiver burden (Vrabec, 1997). The amount of conflict in the relationship can result in negative social support that contributes to stress rather than well-being.

Variations in the Theory of Social Support A concept analysis of social support, based on an examination of 200 studies published from 1978 to 1996, revealed that most studies did not include a specific reference to a theoretical definition of social support and that researchers who defined social support often did not use a definition that addressed the interactional nature of social support (Hupcey, 1998b). Although Hupcey suggested that social support exchanges occur in personal relationships, other scholars have discussed examples of social support provided by professionals or outside the context of personal relationships, such as through communication over the Internet.

Professionals can intervene to strengthen existing social support networks for clients or choose to provide social support when it is lacking by helping individuals and families to access resources in the community that strengthen social support. Schaffer and Lia-Hoagberg (1997) concluded that nurses could provide informational support to partners and others important in the social networks of low-income pregnant women that would enhance the emotional, instrumental, informational, and appraisal support available to the women through their existing social networks. Social support was provided by professionals in a program called the New Mothers Network targeted to single, low-income, African American mothers. Program components included an electronic library, a chat group (asynchronous), and e-mail communication. Advanced practice nurses provided informational, appraisal, and emotional support through e-

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mail discussion and offering encouraging messages in the chat group (Hudson, Campbell-Grossman, Keating-Lefler, & Cline, 2008).

Wright and Bell (2003) explained how social support occurs in computer-mediated support groups. Although communication occurs between participants who do not have close personal relationships, the participants experience emotional support and informational support as they communicate about health-related experiences they have in common. Participants may be more open in expressing emotions since there is greater anonymity and protection from stigmatization in comparison to face-to-face interactions. However, the possibility of negative support exists in the case of hostile messages. Also, there may be greater difficulty in forming long-term relationships, and a diminished reliance on family and friends may occur. On the positive side, evidence suggests that electronic social support may decrease use of health services (Scharer, 2005).

Overlap of other related concepts with social support is also a concern when defining social support. In a study of nurse-provided telephone social support for low-income pregnant women, Finfgeld-Connett (2005) suggested that the telephone-delivered nursing interventions involved something more than the attributes of social support; she reflected that presence may be a subconcept of social support and that social support may have become the default variable for nursing research studies because of the unavailability of instruments for measuring nursing presence.

Variables That Influence Perceptions of Social Support A number of variables affect the social support that is given and received or experienced. These include perceptions of the need and availability for support, timing, motivation for providing support, duration, direction, life stage, the source of support, and social network.

The provider of the social support first recognizes another's need for social support before determining the response to the need. If there is a mismatch in the provider's and recipient's perceptions of the need for support or the type of support that is provided, the recipient may not consider the support to be helpful (Dunkel-Schetter & Bennett, 1990; Dunkel-Schetter & Skokan, 1990). Providers of support may assume that

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the recipient who is experiencing stress needs support. If this assumption is inaccurate, the act of support could result in feelings of dependency, inadequacy, and lower self-esteem (Dunkel-Schetter, Blasband, Feinstein, & Herbert, 1992). Research data suggest that the perception of the availability of support is more important for health and well-being than is the actual receiving of the support (Cohen, Gottlieb, & Underwood, 2001).

Timing is also important, because the support needs of the recipient can change relative to the recipient's appraisal of the situation over time (Jacobson, 1986; Norwood, 1996; Tilden, 1986). Social support is a dynamic process influenced by personal characteristics and situations. Changes that affect both the giving and receiving of social support include the nature of relationships from a historical perspective, expectations of support from one's network, and personal coping skills (Lackner, Goldenberg, Arrizza, & Tjosvold, 1994).

Motivation for providing social support can affect the quality of the support provided. A sense of obligation on the part of the provider may decrease the recipient's satisfaction with the support (Hupcey, 1998a). Providers of social support are likely to consider the recipient's responsibility and effort relative to the needed support and the costs to the provider that result from the act of support (Jung, 1988). The provider's previous experiences with providing support and previous interactions with the intended recipient will also influence choices of support actions (Hupcey, 1998a).

Duration of the support, referring to length of time or stability of the support, is a consideration for the chronically ill and persons who experience long-term loss (Cohen & Syme, 1985). The long-term effects of stressors on individuals may require ongoing support, as well as support from sources outside the usual social networks. For example, in a longitudinal study of the perceived support and support sources of older women with heart failure, the women identified paid helpers as sources of support at a later time in progression of their illness (Friedman, 1997).

The direction of support may be unidirectional or bidirectional. Bidirectional support is characterized by mutuality and reciprocity (Stewart, 1993). Professional support is usually unidirectional. In family and intimate relationships, the roles of “helper” and “helpee” may alternate (Clark, 1983; Rook & Dooley, 1985). Reciprocity in social support is likely to reduce feelings of burden and strain in providers and inadequacy and lack of control in recipients (Albrecht & Adelman, 1987).

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The provision and receiving of social support vary over the life span. Some life stages offer more capability for providing social support, while other life stages require more receiving than giving of social support. Social support needs are greater during times of change and additional stress, such as during the birth of a child or with the loss of strength and function associated with aging.

Individuals often identify family and friends as sources of support in comparison to professionals (Hupcey & Morse, 1997; Schaffer & Lia- Hoagberg, 1997). However, professionals can intervene to enhance the existing social support resources of clients or can act as surrogates to provide support not currently available in the client's social network (Norbeck, 1988). To enhance informal and formal sources of support, professionals can develop and strengthen relationships with personal support networks, mutual aid groups, neighborhood support systems, volunteer programs, and community resources (Chien & Norman, 2009; Froland, Pancoast, Chapman, & Kimboko, 1981). Formal support is more likely to occur in institutional settings. Newsom, Bookwala, and Schulz (1997) found a high degree of formal support for older adults in nursing homes, residential care facilities, and congregate apartments. The instrumental support available in institutional settings was provided primarily by professional and nonprofessional paid staff. These formal support sources may also provide a sizeable amount of emotional support for older adults who have physical and cognitive challenges, because paid staff are more often available for older adults in group residences (Pearlman & Crown, 1992).

The size of the social network is sometimes considered to be an indicator of social support. Key sources of support, including immediate family members and close friends, are distinguished from sources viewed as less important—other relatives, coworkers, church and community members, and professional caregivers (Griffith, 1985). However, a large social network does not necessarily guarantee that a large amount of support is present (Kahn & Antonucci, 1980). The quality of the relationships and availability of persons in the social network, as well as the number of persons in the network, contribute to the enacted social support. A variety of network members can better provide the range of needed social support actions. For example, in one study, persons with a cancer diagnosis perceived spouses or partners as helpful for their physical presence, while friends provided practical help (Dakof & Taylor, 1990). In another study with cancer patients, informational support was perceived as

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helpful from experts but not from friends or families (Dunkel-Schetter, 1984).

The Relationship of Social Support and Health Heller et al. (1986) posited that two facets of social support, esteem- enhancing appraisal and stress-related, interpersonal transactions, have an effect on health outcomes. They hypothesized that the appraisal or perception of the social interaction is health protective, rather than the social interaction or support activity itself. Esteem-enhancing appraisal results from an assessment of how one is viewed by others. In stress- related interpersonal transactions, network members provide tangible assistance, which facilitates coping. Figure 8.1 illustrates these relationships.

Figure 8.1 Hypothesized relationships between facets of social support, coping, and health outcomes. (From Heller, K., Swindle, R.W., & Dusenbery, L. (1986). Component social support processes: Comments and integration. Journal of Continuing and Clinical Psychology, 54(4), 466–470. Copyright © 1986 by the American Psychological Association. Reprinted with permission.)

Cohen et al. (2001) described two models that explain how social support

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influences health. The stress-buffering model holds that social support contributes to health-promoting behaviors in persons who are experiencing stress. Rather than choosing behaviors that may be harmful to health, the support resources strengthen an individual's perceived ability to cope with a stressful situation (Thoits, 1986). These beliefs lead to a calmer psychological and physiological response to the stressful situation and can decrease negative behavioral responses. In this case, an individual is more likely to have an adaptive response to the stressful situation, thus avoiding a maladaptive response with a greater potential for negative health effects.

The main effect model, the second model described by Cohen et al. (2001), suggests that social support directly impacts psychological and physical health, whether or not an individual is experiencing a stressful situation. Integration into a social network, as contrasted to isolation, can provide social control and peer pressure to engage in health-promoting behaviors and lead to positive psychological states, such as a sense of predictability, stability, purpose, belonging, and security (Cassel, 1976; Hammer, 1981; Thoits, 1983). In addition, social networks can provide multiple sources of information about health care services and may also provide informal health care that prevents progression of illness (Cohen et al., 2001).

Norbeck (1981) proposed a model for using social support as a nursing intervention to improve health outcomes. The social support environment of the client is assessed by determining the need for social support compared to the available social support. An assessment of inadequate social support necessitates developing an intervention plan to increase social support. Possible interventions can focus on strengthening the client's existing social support structure or function or providing direct support during a crisis. According to this nursing process model, adequate social support will result in a positive health outcome; inadequate social support without intervention will result in a negative health outcome.

Manning-Walsh (2005) offers a research-based model (consistent with the stress-buffering model) in which social support is a mediator that contributes to improved health outcomes. In a study of women with breast cancer, personal support provided by family and close friends mediated the negative effects of common symptoms contributing to distress during the breast cancer treatment and resulted in improved scores on quality of life measures both generally and specific to breast cancer.

Other studies in nursing have resulted in positive relationships between social support and other variables that contribute to improvements

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in health behavior or positive perceptions about health. In a study of Taiwanese women in early pregnancy, women with higher levels of social support reported less stress; social support along with the additional predictor variables of pregnancy-related nausea and vomiting, perceived stress, and pregnancy planning together explained the variance in maternal psychosocial adaptation (Chou et al., 2008). Keller, Allan, and Tinkle (2006) found that social support from friends increased the time postpartum women spent in physical exercise. In a study of nursing home residents in Norway, Drageset et al. (2009) determined there was a positive relationship between social support and health-related quality of life. In a study of older adults who used senior centers in New York, perceived social support was positively associated with autonomy (Matsui & Capezuti, 2008). Latham and Calvillo (2009) explored predictors of successful diabetes management in a sample of 240 low-income Hispanic people. Social support explained 24% of the satisfaction with quality of life and self on the diabetes quality of life measure. Chien and Norman (2009) conducted a literature review to determine the effectiveness of mutual support groups for family caregivers of people with psychotic disorders. Mutual support groups are “informal networks of individuals who share a common experience or issue” (p. 1618). In the review of 25 studies, they found evidence for short-term positive effects on physical and psychosocial health for clients and families. Benefits included more knowledge about the illness and treatment, lower burden and distress, and better coping ability. The researchers suggested that there should be more studies that investigate the long-term effects of mutual support groups.

While social support can contribute positively to health outcomes, negative social exchanges contribute to negative health outcomes. As a stressor, negative social exchanges bring about the release of stress hormones, which, if continued over time, are damaging to the body. The relationship of negative social exchange and negative health outcomes for elders is evident in lower ratings on self-reports on health status, longitudinal studies on links to heart disease, decline of cognitive functioning, and increased disability (Rook, 2014). Bird-Craven and Massey (2013) found that low-income pregnant women who had a distant or no relationship with the baby's father had higher levels of depressive symptoms. Yang, Schorpp, and Harris (2014) investigated how negative social support, measured by social strain, contributed to inflammation, measured by biological markers. Social strain was defined by interpersonal conflict, frequent criticism, and demands from one's social network. While positive social support protected against the risks of inflammation, social

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strain had a stronger negative influence.

Social Support Nursing Assessment and Interventions For nurses, social support can connect family assessment, patient needs, and health outcomes (Hupcey, 1998b). Beeber and Canuso (2005) suggested five critical assessment questions for nurses to help determine effective emotional, informational, and instrumental social support interventions:

Who helps you get the day-to-day things you need in your life? If you had an emergency, who would you call on for help? Who would lend you money to or keep or ask to keep your child(ren) if you needed it? Who gives you advice that is useful? Who understands your private worries and feelings? (p. 773).

Logsdon and Koniak-Griffin (2005) developed a clinical pathway for social support of postpartum adolescents, which outlines assessment of social support; assessment of related variables such as depression, risk for harm, and high-risk behaviors; and health care provider interventions. They gave examples of specific assessment questions, suggested relevant instruments for the measurement of social support, and identified professional interventions that strengthen existing social support networks. Identified pathway interventions include counseling and teaching about the reality and demands of the postpartum period, common feelings experienced in the postpartum period, options for social support in their network, and the importance of communication as well as providing social skills training and referral for community services. Such interventions can raise the level of perceived appraisal, emotional, informational, and instrumental support.

Vandall-Walker, Jensen, and Oberle (2007) used a grounded theory approach to explore the process of nursing support in a sample of 20 family members from 14 families of critically ill adults hospitalized in intensive care. Family members viewed nursing support as “lightening their load.” Initially, nurses engaged family members through the following support activities: acknowledging, welcoming, orienting,

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relating, trusting, and empathizing. The middle phase focused on sustaining family members through nursing actions of being there, communicating, being accountable, sharing responsibility, negotiating, valuing, promoting family member self-care, and connecting family members to other professionals and services. The final stage of disengaging included providing guidance for decisions, helping to find meaning, and preparing family members to say goodbye, which may involve the client's death or the client leaving the unit. The family members identified nursing support activities that helped them to “get through” the situation, which is different than conceptualizations of support as caring (Vandall-Walker et al., 2007). Many of these nursing actions will likely result in the provision of emotional, informational, instrumental, and appraisal support to families of critically ill adults.

In another intervention example, telephone peer support was provided during the postpartum period to prevent postpartum depression (Dennis, 2010). A peer volunteer initiated telephone conversations for the intervention group. Participants completed the Peer Support Evaluation Inventory (PESI). Mothers reported receiving emotional, informational, and appraisal support through conversations with the peer volunteers. There was a positive relationship between maternal satisfaction and the number and duration of peer contacts. Researchers recommended strengthening appraisal support and matching volunteers to participant characteristics.

Application of the Theory in Practice Nurses have the knowledge and expertise to assess the interpersonal and social environments of clients, implement health promotion strategies, and facilitate clients in initiating self-care practices (Tilden, 1985). From a prevention perspective, social support can be viewed as “social inoculation” (Pilisuk, 1982). Through “network therapy,” nurses can assess social support adequacy, use existing social support measures, determine the roles of professionals and nonprofessional providers of social support to move clients to increasing independence, and organize and evaluate community support groups (Roberts, 1984). Using Middle Range Theory in Practice 8.1 provides an example of a social support intervention for promoting physical activity among Hispanic women.

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USING MIDDLE RANGE THEORY IN PRACTICE 8.1

Source: Fleury, J., Keller, C., & Perez, A. (2009). Social support theoretical perspective. Geriatric Nursing, 30(2S), 11–14. doi: 10.1016/j.gerinurse.2009.02.004.

Problem A major health problem for Hispanic women is obesity. A sedentary

lifestyle among Hispanic women contributes to both obesity and the risk for cardiovascular disease. Physical activity is a protective factor against obesity, which is a risk factor for cardiovascular disease.

Nursing Intervention Mujeres en Accion por Su Salud is a program for promoting

physical activity among Hispanic women. Social support theory guided the development of the program. Peer counselors or lay health educators (promotoras) provide emotional, instrumental, appraisal, and informational support to women. A promotora is a community member that others consult for care, advice, information, and help in overcoming barriers to healthy activity. Behaviors are influenced by belonging to social groups. Women participate in 12 group sessions and 12 booster sessions. Promotoras complete a training program and follow intervention protocol.

Social support actions (aid and assistance) occur in the social relationships and interpersonal transactions that take place in the program. Emotional support consists of offering empathy, caring, and trusting relationships. Instrumental support offers specific aid (goods or services). An example is accompanying women on safe walking routes. Appraisal support would be offering comments or evaluation that affirms positive action, leading to a positive self-concept. Providing advice, suggestions, and specific information is an action consistent with informational support.

Conclusions Social support interventions are culturally relevant and occur in

groups in which women provide support to one another. Mujeres en

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Accion por Su Salud provides the resource of social support in a culturally relevant community setting. The social support is expected to contribute to improved cardiovascular status through regular physical activity.

An example of preventive support is comprehensive home visitation for vulnerable young mothers provided by public health nurses (Olds et al., 2007). Nurses provided regular home visits to young mothers beginning during their pregnancy and continuing until their children were 2 years of age. The purposes of the visits were to improve pregnancy outcomes, to promote children's healthy development, and to improve the financial self- sufficiency of participating families. Nurses both provided formal support and strengthened informal sources of support. Evaluation of the long-term outcomes through a randomized clinical trial demonstrated positive outcomes for mothers (reduced subsequent birth rate, longer interval between first and second birth, and more relationship stability) and children (higher academic achievement and lower mortality from preventable causes).

Stewart (1989b) offered a practice application framework consisting of five social support intervention levels: individual, dyadic, groups, community, and social system. Interventions at these levels include strengthening available social support and providing direct social support with the goal of improving health status. At the individual level, a home care nurse could provide informational, appraisal, and emotional support for a pregnant woman placed on bed rest for a high-risk pregnancy. The nurse may also help the woman identify instrumental support for help with household tasks. At the dyadic level of social support, an oncology nurse who is providing care for a woman having a mastectomy would include the woman's partner in social support interventions such as referral to couples' counseling. At the group level, a nurse could refer a patient with multiple sclerosis and the family members to a support group that would provide informational and emotional support. An example of a community-level support intervention is the Block Nurse Program, which provides informational and instrumental support to isolated elderly in a neighborhood. Finally, a systems example is the establishment of school policy to promote healthy eating. Informational support for parents and school staff, instrumental support through changes in breakfast and lunch offerings to promote healthy eating, and appraisal support through a peer group to encourage positive behavior change all contribute to motivation

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for healthy eating behaviors. Table 8.2 provides citations and descriptions of specific applications of social support theory in clinical practice.

Table 8.2 Examples of Theory in Practice

Application of the Theory in Research Researchers have explored a great variety of nursing practice issues from a social support perspective including topics such as chronic illness, persons

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who are grieving, the relationship of social support to acute chest complaints, new mothers in stressful situations, and administrative support for nurses. Researchers have also investigated how social support interacts with other variables to predict health outcomes. The majority of studies focus on the individual- or family-level experience of social support. In Middle Range Theory in Research 8.2, there is an example of how social support theory has been used in research. Table 8.3 lists additional examples on social support research in nursing.

USING MIDDLE RANGE THEORY IN RESEARCH 8.2

Source: Zabakegui, A., Cabrera, E., Navarro, M., & Cebria, M. I. (2011). Perceived social support and coping strategies in advanced cancer patients. Journal of Research in Nursing, 18(5) 409–420. doi: 10.1177/1744987111424560

Research Question What are the relationships among demographic variables, medical

variables, perceived social support, and coping strategies in patients with advanced cancer?

Research Design Descriptive correlational

Sample/Participants The sample included 132 advanced cancer patients who were

receiving chemotherapy for palliative treatment; participants were recruited from two metropolitan New York hospitals. The final samples included 88 women and 44 men, had a mean age of 60.24, were primarily Caucasian (86%), married (63%), and educated beyond high school (67%).

Data Collection Measures included part 2 of the Personal Resource Questionnaire-

85 (PRQ85) and the Ways of Coping Inventory–Cancer Version (WOC- CA). Medical data were collected from hospital records. Part 2 of the

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PRQ85 has 25 items on a seven-point Likert scale and measures perceived social support. The WOC-CA measures coping strategies for responding to problems related to cancer, has 53 items, and uses a five- point Likert scale with five subscales: seeking and using social support, focusing on the positive, distancing, cognitive escape–avoidance, and behavior escape–avoidance.

Findings There was a significant relationship between perceived social

support (environmental resource) and seeking and using social support (coping strategy) (r = 0.27, p < 0.001). Individuals with higher levels of social support also had a greater positive focus. In addition, perception of health was positively related to perceived social support (r = 0.28, p < 0.001). The study supports theoretical links between social support and coping strategies for patients with advanced cancer.

Table 8.3 Examples of Research for Application to Practice

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Measures of Social Support Although a great number of social support measures have been developed in several disciplines, many measures do not have adequate reliability and validity testing, and many are situation-specific rather than general measures of social support. Available measures address (1) interconnectedness in a social network; (2) received support, based on a person's report of support that was provided; and (3) perceived support, the support a person believes to be available to him or her (Sarason et al., 1990). Researchers have primarily developed situation-specific measures of social support for groups who encounter a common stressor event, such as pregnancy or chronic illness (Stewart, 1993). Of 21 social support instruments reviewed by Stewart (1989a), only four were applicable on a general level. Eight measures of social support developed by nurse researchers are described in Table 8.4. The selected instruments represent both general and specific measures of social support and have been psychometrically analyzed. None of the instruments are applicable to young children. Additional measures of social support that have been used by but not developed by nurse researchers are listed at the bottom of the table.

Table 8.4 Selected Social Support Instruments Developed by Nurse Researchers

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Note: Additional Measures of Social Support Used by Nurse Researchers

Family Functioning, Health, and Social Support (FAFHES)—Social support portion has 37 items for aid, affirmation, and affect subscales (Astedt-Kurki, Tarkaa, Rikala, Lehti, & Paavilainen, 2009). Family Support for Exercise Scale (Sallis, Grossman, Pinski, Patterson, & Nader, 1987). Friend Support for Exercise Scale (Sallis et al., 1987).

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Interpersonal Support Evaluation List (ISEL)—15 items include appraisal, belonging, and tangible support (Cohen, Mermelstein, Kmarack, & Hoberman, 1985; Owen, 2003). Medical Outcome Study Social Support Survey (Holden, Lee, Hockey, Ware, & Dobson, 2014; Sherbourne & Stewart, 1991; ). Multidimensional Scale of Perceived Social Support (MSPSS)—12 items include significant other, family, and friend subscales (Zimet, Dahlem, & Zimet, Dahlem, Zimet, & Farley, 1988). Postpartum Social Support Questionnaire (PSSQ) (Hopkins & Campbell, 2008). Social Support for Physical Activity Scale—4 items measure support from kin, nonkin, and health care workers (Cousins, 1996).

Most measures of social support are self-reports. Newsom et al. (1997) discussed the challenge of measuring social support for the cognitively impaired. They suggested that proxy and observational measures of social support may be an alternative strategy for determining the adequacy of social support for persons who cannot provide an accurate self-report. Proxies, such as nursing home staff and primary caregivers, can provide information about social network contacts and interactions. Observational methods include recording interaction behaviors and videotaping. A coding system can be used to label the source of the support, the type of support, the recipient response, and other characteristics of the support interaction.

Some researchers have used qualitative approaches for investigating social support, although quantitative measures appear to be predominant. In Finland, nurse researchers asked one open-ended question to explore perceptions of social support after the death of a spouse: “What helped you cope with your grief?” (Kaunonen, Tarkka, Paunonen, & Laippla, 1999). The researchers used content analysis to classify the data by the structure of social relationships and the social support functions of aid, affirmation, and affect in relationships (Kahn, 1979). Lugton (1997) used a strategy called social contact analysis, in addition to interview data, to explore the social support experienced by women treated for breast cancer. Participants drew their social networks, with self at center, using shorter lines for closer relationships and arrows to indicate whether the relationship involved support, strain, or both. The researcher then asked participants to describe how professional and informal persons in the social network had responded to the illness of the participant in supportive

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and nonsupportive ways. Types of support that facilitated adjustment were emotional support, companionship, practical help, opportunities for confiding, experiential support (from others who had experienced breast cancer), and sexual identity support.

Evans, Donelle and Hume-Loveland (2012) conducted a content analysis of messages posted in an online postpartum depression support group over 6 months. The analysis revealed that the online discussion provided emotional, informational, and instrumental support for women who were experiencing postpartum depression. Participants were able to express their feelings, perceived they were understood, and could share their emotional distress.

Challenges to Social Support Theory Development and Research Future efforts in social support theory development and research need to move from a description of the relationship of social support and health outcomes to the investigation of interactional characteristics, negative aspects, gender and cultural contexts, causal relationships in social support, and effective social support interventions. In particular, multilevel interventions that address both interpersonal support and community-level environmental support could contribute to knowledge about cost-effective social support strategies for improving the health status of populations.

Because researchers have used a variety of definitions of social support and have measured different aspects of social support, it is difficult to compare study results (Heitzmann & Kaplan, 1988; Roberts, 1984). Hupcey (1998b) commented that many other concepts, such as marital status and frequency of contact, have often been included in definitions of social support. To determine effectiveness of social support, an understanding of the perceptions of the providers of social support as well as those of the recipient merits further exploration (Hupcey, 1998b). The reciprocity of social support is an interactional variable that can contribute to understanding effective social support interventions.

Middle range social support theory development could be enhanced by greater exploration of the negative effects of informal social support. Many social support measures do not include negative aspects of

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relationships (Krishnasamy, 1996; Stewart, 1993). In a review of 50 studies on social support and caregiver burden, Vrabec (1997) recommended further examination of the amount of conflict in the social support network as a predictor of caregiver burden. The Interpersonal Relationships Inventory (IPRI) is one of the few measures that attempts to encompass the full context of relationships through inclusion of reciprocity and conflict subscales (Tilden, Nelson, & May, 1990).

Social support measures also need to be sensitive to the cultural context (Ducharme, Stevens, & Rowat, 1994). Higgins and Dicharry (1991) evaluated the Personal Resources Inventory Part 2 (PRQ) for its applicability to Navajo women. They found that 10 of the 25 items were not applicable to Navajo culture. The 10 items were considered too personal because in the Navajo culture, family problems and feelings are not discussed with others. Different cultural groups may vary in perceptions of the number of persons they consider to be a part of their social network, as well as the relative importance of the different components of social support. Expectations for independence and help may differ. Some types of assistance could be expected and appreciated by one culture and be interpreted as shameful by another culture.

In a study on types of social support in African Americans with cancer, Hamilton and Sandelowski (2004) found that although the broad categories of social support were applicable to the African American sample, strategies for perceived helpful social support differed from Caucasian populations. African Americans perceived presence and distracting activities as emotional support in contrast to verbal expressions of problems. Instrumental support included offers of prayer and other kinds of assistance that were less often identified in other studies of social support.

Martinez-Schallmoser, MacMullen, and Telleen (2005) suggested specific assessment questions that are adapted to the social support needs of the Mexican American pregnant women population. The meaning of social support across cultures needs further exploration. In addition, males are a neglected population in social support research (Langford et al., 1997). Qualitative research approaches could be useful for discovering meanings of social support across cultures.

Causality in social support research needs further exploration. Researchers have conducted many descriptive and correlational studies that link social support to positive health outcomes, but fewer studies substantiate causal links (Callaghan & Morrissey, 1993). The impact of

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health status on how people seek and receive support has been explored less often than the effects of social support on health status (Stewart, 1993). Changes in health status are likely to influence the amount of and components of social support that are needed. With increased stress resulting from threats to health, social support actions can facilitate positive or problem-focused coping. Moreover, the balance of reciprocity in relationships and the amount of conflict present may change in response to health status changes. One question suggested by Cohen et al. (2001) for future study is whether persons with chronic illness decrease their provision of support, resulting in an imbalance in the social network (reciprocity). The explosion of social media and networking is another important focus for research on social support interventions. A comparison of interventions delivered through different modes of communication (face-to-face, telephone, Internet) on specific types of support would add to understanding how to deliver effective social support interventions.

To further develop understanding of the linkages of social support to health outcomes, theoretically based social support interventions need to be tested in controlled intervention trials across varied settings and age groups (Ducharme et al., 1994). Cohen et al. (2001) suggested that more intervention research should be conducted on promising interventions, such as support groups and support provided in dyads (partner or peer support). In addition, research on interventions that focus on strengthening the social support environments at a community or systems level can develop knowledge about how to use social support to improve the health status of populations. Multilevel interventions may be the most effective. Rook and Dooley (1985) described two categorical approaches to social support interventions—individual and environmental. Individual interventions are used to change how a person perceives or seeks support, while an environmental approach targets the community to improve the social support climate. Social support is likely to be maximized with the implementation of both approaches. Research methods used to test the effectiveness of social support interventions need to be tailored to the intervention level. Measures for any level should include the potential negative aspects of social support in the person's interactions and environment, which, if not considered, can confound the interpretation of study findings. Evaluation of social support interventions at the individual, dyadic, and group levels is likely to focus on the perceptions of social support actions and available support. Evaluation of social support interventions at the community and systems levels emphasizes analysis of social support available in networks and the environment.

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Summary There is a lack of consensus on the definition of social support. There are numerous measures of social support; many are for specific situations. Future theory development should include negative aspects of social support and provision of support at the community and societal levels. Future research on social support should address the effectiveness of social support interventions, including support from social media and networking. Social support theory is important to nurses because it can explain and suggest nursing interventions to improve health outcomes.

Critical Thinking Exercises

1. Compare two options for providing a social support intervention for parents of children diagnosed with a chronic mental illness: (1) a nurse-led monthly face-to-face meeting of parents (with child care provided) and (2) an asynchronous Internet discussion for the parents.

2. Look at the list of definitions of key terms. Use the key terms to analyze the nature of the social support experience that could be expected from each of the two interventions.

3. Analyze how each of the interventions is consistent or inconsistent with Hupcey's definition of social support.

4. Design evaluation studies, using both quantitative and qualitative approaches, to measure the experience of social support and effectiveness of the intervention for each of the two options. Consider the reliability and validity of suggested measurement strategies.

5. Analyze how the following variables may affect the experience of social support in each of the two options: perceptions of the need for and availability of support, timing, motivation for providing support, duration, direction, life stage, sources of social support, and social network.

6. Analyze the potential effectiveness (improved health outcomes and

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coping) resulting from professional or nurse-provided social support versus enhancement of social support provided by personal relationships and social networks for parents of children with a chronic mental illness.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources. You can also critique the body of knowledge presented in Chapter 8 using the criterion that appears in the Analysis of Theory exercise associated with this chapter.

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9 Caring Danuta M. Wojnar

Definition of Key Terms

Caring A nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility (Swanson, 1991, p. 165)

Knowing Striving to understand an event as it has meaning in the life of the other. Knowing involves avoiding assumptions about the meaning of an event to the one cared for, centering on the other's needs, conducting in-depth assessment, seeking verbal and nonverbal cues, and engaging the self of both (p. 163).

Being with Being emotionally present to the other by conveying ongoing availability, sharing feelings, and monitoring that the one providing care does not burden the one cared for (p. 163)

Doing for Doing for the other what he or she would do for the self if it were at all possible. Doing for the other means providing care that is comforting, protective, and anticipatory, as well as performing duties skillfully and competently while preserving the person's dignity (p. 164).

Enabling Facilitating the other's passage through life transitions and unfamiliar events by informing, explaining, supporting, focusing on relevant concerns, thinking through issues, and generating alternatives. Enabling promotes the client's personal healing, growth, and self-care (p. 164).

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Maintaining belief Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning. The goal is to enable the other so that within the constraints of his or her life, they are able to find meaning and maintain a hope-filled attitude (p. 165).

Introduction Nursing, like other health professions, is based on the ideal of service to humanity. At the core of nursing values lies the ideal of altruistic caring that is guided by theory, research, and a code of ethics. Nursing is focused on creating caring–healing environments that assist individuals, families, and communities attain or maintain a state of optimal wellness in their life experiences from birth, through adulthood, until the end of life (Swanson & Wojnar, 2004). Most individuals choose nursing as a profession because of their desire to care for others. With advances in nursing science, there has been an escalating interest in the concept of caring in nursing. Over the past few decades, philosophical debates, research, and theory development have ensued to define the concept of caring, articulate caring behaviors, and identify outcomes of caring for patients, families, nurses, organizations, and society. Also of deep concern is detecting and eliminating barriers to caring in clinical practice. Among several prominent frameworks, Swanson's middle range Theory of Caring has achieved popularity among practitioners because of its simplicity, elegance, relevance, and ease of application in education, research, and clinical practice.

Historical Background Nursing has a long legacy as a caring–healing profession. In the 19th century, Florence Nightingale, the matriarch of modern-day nursing, expressed a belief that caring for the sick is based on the understanding of persons and environment. She saw the uniqueness of nursing in creating optimal environments for restoring the health of individuals, a vision that has now been in operation for over 100 years (Chinn & Kramer, 2004).

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Nurse theorists, such as Watson (1979, 1988, 1999), Leininger (1981, 1988), Benner (1984), Benner and Wrubel (1989), Boykin (1994), Swanson-Kauffman (1985, 1986, 1988a, 1988b), Swanson-Kauffman and Roberts (1990), and Swanson (1991, 1993, 1998, 1999a, 1999b, 1999c) have reaffirmed the importance of caring for the profession through philosophical debates, theory development, and groundbreaking research. These scholars have led the profession in reminding nurses that caring is essential for delivery of sound nursing care.

Theory Development Swanson's interest in the caring science has been a rapid process. As a novice nurse, she was drawn to working in clinical site that had a clearly articulated vision for professional nursing practice and actively supported primary care nursing (Swanson, 2001). During the theorist's doctoral studies at the University of Colorado, the concept of caring went to the forefront of her professional and scholarly activities, and from that point on, caring and miscarriage have become the foci of her scholarship. For her doctoral dissertation, Swanson set out to conduct descriptive phenomenological investigation of twenty women who had recently miscarried and to identify what types of caring behaviors they considered most helpful (Swanson, 1991). Inductive data analysis led Swanson to the development of a Caring Model with five distinct caring processes: knowing, being with, doing for, enabling, and maintaining belief (Swanson, 1991, 1993; Swanson-Kauffman, 1985, 1986, 1988a). These caring processes provided foundation for the development of Swanson's middle range Theory of Caring.

In a subsequent investigation, Swanson focused on exploring caring from the perspective of 19 professional caregivers and 7 parents of infants hospitalized in the neonatal intensive care unit (NICU) (Swanson, 1990). She discovered that the caring processes she had identified through her dissertation research were also applicable to parents and professionals who were responsible for taking care of babies in the NICU. Swanson not only was able to retain and refine the definitions describing the acts of caring but also was able to propose that clinical care in a complex environment requires balance of caring for self and others, attaching to others as well as one's role, managing responsibilities, and avoiding bad outcomes for self, others, and society (Swanson, 1990). The next phase in development of

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Swanson's Caring Theory was the “Caring and the Clinical Nursing Models Project” in which Swanson explored how a group of young mothers who received a long-term public health nursing intervention recalled and described nurse caring (Swanson-Kauffman, 1988b). Based on the findings of this study, Swanson defined caring as a concept and refined the definitions of caring processes (Swanson, 1993).

Later on, Swanson's scholarship has shifted to conducting a meta- analysis of data-based publications about caring (Swanson, 1999a) and instrument development. Swanson established psychometric properties of several instruments to measure caring, including Caring Other Scale (Table 9.1) and Caring Professional Scale (Table 9.2). Among other measures, she used the above instruments to determine the impact of support after miscarriage on women (Swanson, 1999b, 1999c, 2000; Swanson, Connor, Jolley, Pentinato, & Wang, 2007; Swanson, Karmali, Powell, & Pulvermakher, 2003) and couples (Swanson, Chen, Graham, Wojnar, & Petras, 2009).

Table 9.1 Caring Mate/Caring Other Scale

Swanson (1999a, 2002).

Table 9.2 Caring Professional Scale

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I. About the nurse, physician, provider, etc. Directions: It is very important that you give us honest feedback on your experience. When you are done, your evaluation will be placed in a sealed envelope and will not be seen by your nurse, provider, etc. Please answer the questions about the nurse, provider, etc., you just met with.

Over the past decade, Swanson has focused on dissemination of her theory as an invited guest speaker in various health care organizations across the United States and internationally, assisting others in evaluating the impact of Caring Theory when it is used as a framework to guide clinical practice. Some examples of Swanson's Caring Theory impact on clinical practice have been described in recently published works by Higdon and Shirey (2012); Jennings, Heiner, Hemman, and Swansion (2005); Kavanaugh et al. (2013); Swanson et al. (2009); Tonges, McCann, and Strickler (2014); Tonges and Ray (2011); and Wang and Hsu (2014).

Definitions of Theory Concepts In 1993, Swanson refined her theory by making explicit her beliefs about the four phenomena of concern to the discipline of nursing: nursing, person/client, health, and environment. The concept of caring, central to

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the theory, as well as caring processes (knowing, being with, doing for, enabling, and maintaining belief) are clearly defined and arranged in a logical sequence. The Structure of Caring, Figure 9.1, depicts how caring is delivered. Swanson also made explicit her beliefs about what it means for nurses to practice in a caring manner to promote health and healing of others. Chinn and Kramer (2004) and Meleis (1997) maintain that the simplicity and clarity of a theory refer to a theory with a minimal number of concepts. Simplicity and clarity of language used to define the concepts allow practitioners to understand and apply Swanson's theory in practice.

Figure 9.1 The structure of caring as linked to the nurse's philosophical attitude, informed understandings, message conveyed, therapeutic actions, and intended outcome. (Reprinted with permission from Swanson, K. M. (1993). Nursing as informed caring for the well-being of others. Image: The Journal of Nursing Scholarship, 25(4), 352–357.)

Nursing Swanson (1991, 1993) defines nursing as informed caring for the well- being of others. She posits that the discipline is informed by scientific knowledge from nursing and related fields and by knowledge derived from the humanities, clinical practice, and cultural values and beliefs (Swanson, 1993).

Person

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Persons are defined as “unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (Swanson, 1993, p. 352). Swanson asserts that life experiences of each individual are influenced by a complex interplay of genetics, spiritual endowment, and the person's capacity to exercise free will. Therefore, persons both shape and are shaped by the environment in which they live.

Persons are viewed as dynamic, growing, self-reflecting, yearning to be connected with others, and spiritual beings. Swanson posits that spiritual endowment connects each human being to an eternal and universal source of goodness, mystery, life, creativity, and serenity. The spiritual endowment may be a soul, higher power/Holy Spirit, positive energy, or, simply, grace; free will equates with choice and the capacity to decide how to act when confronted with a range of possibilities (p. 352). Yet, she also maintains that limitations set by race, class, gender, sociopolitical system, or access to care might prevent individuals from exercising free will. Hence, acknowledging free will mandates nursing discipline to honor individuality and consideration of a whole range of possibilities that might be acceptable or desirable to the patients, families, and communities for whom nurses care.

According to Swanson, the “other,” whose personhood nursing discipline serves, refers to individuals, families, groups, and societies. With this understanding of personhood, nurses are mandated to take on leadership roles in advocating for human rights, equal access to health care, and other humanitarian causes. Lastly, when nurses think about the “other” to whom they direct their caring, they also need to think of self, other, nurses, and the practice of nursing as the designated “other/recipient” of their caring.

Health According to Swanson (1993), to experience health and well-being is to have a subjective, meaning-filled experience of wholeness that involves a sense of integration and becoming wherein all levels of being are free to be expressed including human spirituality, thoughts, feelings, intelligence, creativity, relatedness, femininity, masculinity, and sexuality, to name just a few. Therefore, reestablishing wholeness involves a complex process of curing and healing at the physical, mental, psychosocial, and spiritual

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levels.

Environment Swanson (1993) defines environment as situational rather than physical and views environment as any situation that influences or is influenced by the designated client. Environment is ever changing at the cultural, social, biophysical, political, and economic realms and by any context that influences or is influenced by the designated client. She believes that the terms “environment” and “person/client” in nursing can be viewed interchangeably since the environment may be specified to the intraindividual level of a specified client, wherein the “client” may be at the cellular level and the environment may be the tissues or body of which the cell is a component, or the client may be an entire community and its environment include cultural, social, and political aspects (p. 353). Therefore, when Swanson's theory is used in research or clinical practice, one must remember that what is considered an environment in one situation may be considered a client in another.

Caring Swanson believes that nurse caring is grounded in a belief in people and their capacities. Therefore, caring is defined as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Swanson maintains that caring involves five processes: (1) knowing, (2) being with, (3) doing for, (4) enabling, and (5) maintaining belief. For detailed definition of the caring processes, refer to the beginning of the chapter, Definitions of Key Concepts section.

Description of the Theory of Caring

Philosophical Foundation Swanson has drawn on various philosophical and theoretical sources while

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developing her Theory of Caring. In the chapter “The Program of Research on Caring,” Swanson (2001) recalled that early on in her career, knowledge obtained from formal nursing education and clinical practice made her acutely aware of the centrality of caring to preserving human dignity and promoting healing. Swanson also acknowledged several nurse scholars for influencing her beliefs about nursing and caring. She credits Dr. Jacqueline Fawcett for helping her understand the unique role of nursing in caring for others and importance of altruistic caring for the persons' well-being. Swanson also acknowledges Dr. Jean Watson for encouraging her to inductively study caring. While Drs. Swanson and Watson sustain a deep friendship and respect for each other's scholarship, they both view their scholarship as complementary. They view their programs of research as unique and believe the congruency of their findings adds credibility to each other's work. Yet, both scholars see their Theories of Caring and their programs of research on caring as unique and the congruency of their findings as adding credibility to their individual work (Swanson, 2001). Lastly, Swanson credits Dr. Kathryn M. Barnard for encouraging her to test and apply her Theory of Caring through randomized clinical trials.

Swanson's theory was developed empirically, using inductive methodology. According to Chinn and Kramer (2004), inductive reasoning involves inducing of hypotheses and relationships by observing or living through phenomena and before reaching definite conclusions. Swanson's Theory of Caring was inductively developed through descriptive phenomenological inquiry with women who had miscarried (Swanson- Kauffman, 1985, 1986, 1988a, 1988b), caregivers of vulnerable infants in the NICU (Swanson, 1990), and socially at-risk mothers who had received long-term care from master's prepared public health nurses (1991).

Theoretical Assumptions Swanson purports that caring, which she defines as “a nurturing way of relating to a valued other toward whom a nurse feels a sense of commitment and responsibility” (1991, p. 162), is not unique to the domain of perinatal nursing. Instead, she posits, caring is an essential component of nurse–client relationship in any setting. Swanson also purports that caring occurs in every nurse–client relationship that involves skillful application of caring processes (knowing, being with, doing for,

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enabling, and maintaining belief). She also posits that regardless of the amount of nursing experience, caring is influenced by the nurse's attitude (maintaining belief), understanding of client's experience (knowing), verbal and nonverbal interaction with the client (being with), enabling (believing in the client's capacity to live through difficult transitions), and outcomes of caring (intended outcomes of nursing process). Swanson purports that caring processes coexist and overlap and cannot be delivered in a linear way or in separation from one another. Lastly, Swanson claims that if she had truly identified and defined the universal aspects of caring, then her caring processes should ring true in any situation where caring is a part of an interpersonal relationship. Swanson (1993) depicted the caring processes and the relationships between them in the Structure of Caring, as represented in Figure 9.1.

Application of the Theory in Research Reynolds (1971) suggests that a functional theory is one that can be applied in clinical practice and research. Swanson has persevered in the development of her theory from the point of defining the concept of caring and caring processes in her Caring Model to the development of middle range Theory of Caring, descriptive research to determine human responses to miscarriage over time, and theory testing using randomized controlled trial design.

Specifically, in her dissertation research, the theorist analyzed data obtained from in-depth interviews with 20 women who have recently miscarried. Two theoretical models were proposed as a result of this phenomenological investigation: (1) the Human Experience of Miscarriage Model and (2) the Caring Model. The Caring Model, in which Swanson proposed that the processes of knowing, being with, doing for, enabling, and maintaining belief, give meaning to nursing acts labeled as caring (Swanson-Kauffman, 1985, 1986, 1988a, 1988b). Findings of this investigation provided the foundation for the development of middle range Theory of Caring at a later time.

As part of her postdoctoral studies, Swanson conducted another phenomenological investigation, in which she explored “what was it like

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to be a provider of care to vulnerable infants in the NICU?” As a result of this study, Swanson (1990) found that the caring processes she identified with women who miscarried were also applicable to parents, physicians, and nursing staff responsible for taking care of infants in the NICU. Therefore, Swanson decided to retain the wording describing the acts of caring and proposed that wholistic care in a complex environment like NICU embraces balance of caring (for self and the one cared for), attaching (to others and roles), managing responsibilities (assigned by self, others, and society), and avoiding bad outcomes (Swanson, 1990).

In a later investigation, Swanson (1991) explored what it had been like for socially at-risk mothers to receive supportive, long-term nursing interventions. As a result of this study, she was finally able to define caring and further refine the definitions of caring processes. Collectively, findings of Swanson's research with women who have miscarried, caregivers in the NICU, and socially at-risk mothers provided the foundation for expanding the Caring Model into the middle range Theory of Caring (Swanson, 1991, 1993).

Swanson tested her Theory of Caring with women who miscarried in several investigations funded by the National Institutes of Health, National Institute of Nursing Research, and other funding sources. Swanson's (1999a, 1999b) intervention study with 242 women who miscarried focused on examining the effects of caring-based counseling sessions on the women's processing of loss and their emotional wellness in the first year after loss. Additional aims of the study were to examine the effects of the passage of time on healing and to design strategies to monitor caring interventions. The main findings of this investigation were that caring was effective in decreasing the participants' overall disturbed mood, depression, and anger. Moreover, all study participants (treated or not) assigned less personal significance to miscarrying and had higher levels of self-esteem and less anxiety, anger, and confusion. In other words, the findings of the study demonstrated that while passing of time had positive effects on women's healing after miscarriage, caring interventions had a positive impact on decreasing the overall disturbed mood, anger, and level of depression. The second aim of this investigation was to monitor the caring variable and identify whether caring was delivered as intended. In this investigation, caring was monitored in three different ways: (1) approximately 10% of counseling sessions were transcribed and data were analyzed using inductive and deductive content analysis; (2) before each caring session, the counselor completed McNair, Lorr, and Droppelman's

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(1981) Profile of Mood States to monitor whether her own mood was associated with women's ratings of caring after each session, using the investigator-developed Caring Professional Scale; and (3) after each session, the counselor completed an investigator-developed Counselor Rating Scale and took narrative notes about the counseling session. The most noteworthy finding of monitoring caring was that the majority of participants were highly satisfied with caring received during counseling sessions, suggesting that caring was delivered as intended.

In 2009, Swanson and her research team published results from the National Institutes of Health (NIH)-funded intervention research “Couples Miscarriage Healing Project” (Using Middle Range Theory in Research 9.1) conducted with (N = 341) heterosexual couples over a period of 1 year after loss (Swanson, Chen, Graham, Wojnar, & Petras, 2009). The study was conducted to determine the effects of miscarriage on couples in committed heterosexual relationships and to identify effective ways of helping couples heal both as individuals and as couples subsequent to miscarriage. Study participants (couples) were randomly assigned to one of three treatment groups: (1) nurse caring (three counseling sessions with a nurse), (2) self-caring (SC) (three videos and workbook modules), (3) combined caring (CC) (one nurse caring session and three videos and workbook modules), or (4) a control group (no intervention). Interventions, based on Swanson's Caring Theory and Meaning of Miscarriage Model, were offered 1, 5, and 11 weeks after enrollment. Differences in rates of recovery were estimated via multilevel modeling conducted in a Bayesian framework. Swanson et al. (2009) found that caring-based interventions delivered by Registered Nurse had the overall broadest positive impact on couples' resolution of grief and depression. In addition, grief resolution was accelerated by SC intervention for women, and combined nurse and SC intervention for men, suggesting that Swanson's Caring Theory is an effective framework to facilitate healing of individuals and couples in clinical practice.

USING MIDDLE RANGE THEORY IN RESEARCH 9.1

Source: Swanson, K. M., Chen, H., Graham, J. C., Wojnar, D. M., & Petras, A. (2009). Resolution of depression and grief during the first

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year after miscarriage: A randomized controlled trial of couples-focused interventions. Journal of Women's Health, 18(8), 1245–1257.

Purpose/Research Question The purpose of this study was to examine the effects of three

couple-focused interventions and a control condition on women and their partners' resolution of depression and grief during the first year after miscarriage.

Research Design A randomized controlled clinical trial (RCT) was used in this study.

Sample/Participants Three hundred and forty-one couples participated in the study. They

were enrolled within the first 12 weeks after pregnancy loss.

Data Collection Subsequently, couples who met the inclusion criteria were randomly

assigned to nurse caring intervention (NC) that entailed three counseling sessions: SC that consisted of three video and workbook modules, CC that included one counseling session plus three SC modules, or controlled condition in which no treatment was offered. Interventions were based on Swanson's Caring Theory and Meaning of Miscarriage Model. They were offered 1, 5, and 11 weeks after enrollment. Outcomes included depression (CES-D) and grief, pure grief (PG), and grief-related emotions (GRE). Couples' perceptions of Caring Professional and Caring Mate and Caring Other Scales in the aftermath of loss were also administered to all participants. Differences in rates of recovery were estimated via multilevel modeling conducted in a Bayesian framework.

Findings Swanson et al. (2009) found that Bayesian odds (BO) ranging from

3.0 to 7.9 favored NC over all other conditions for accelerating women's resolution of depression. BO of 3.2 to 6.6 favored NC and no treatment over SC and CC for resolving men's depression. BO of 3.1 to 7.0 favored all three interventions over no treatment for accelerating women's PG resolution, and BO of 18.7 to 22.6 favored NC and CC over SC or no treatment for resolving men's PG. BO ranging from 2.4 to 6.1 favored NC and SC over CC or no treatment for hastening women's

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resolution of GRE. BO from 3.5 to 17.9 favored NC, CC, and control over SC for resolving men's GRE. Swanson et al. (2009) concluded that NC had the overall broadest positive impact on couples' resolution of grief and depression. In addition, grief resolution (PG and GRE) was accelerated by SC for women and CC for men.

Reynolds (1971) asserts that a useful theory provides a sense of understanding and applicability in research, education, and practice. The Caring Theory has been the theoretical foundation for numerous research studies, masters and doctoral dissertations, and scholarly projects of undergraduate and graduate nursing students. Literature review of computerized data bases (MEDLINE, CINAHL, and Digital Dissertations) indicates that Swanson's theory and research have been cited or otherwise utilized in over 160 data-based publications, while the article “Nursing as Informed Caring for the Well-Being of Others” (Swanson, 1993) alone has been cited over 50 times. Recent applications of Swanson's Caring Theory in research include the following publications: Kish and Holder's (1996) exploration of clinical scholarship in practice; Yorkston, Klasner, and Swanson's (2001) guidelines for practitioners working with patients who have multiple sclerosis; Quinn, Smith, Ritenbaugh, and Swanson's (2003) guidelines for assessing impact of healing relationships in nursing; Sikma's (2006) study of caring with elderly population; Kavanaugh, Moro, Savage, and Mehendale's (2006) research with vulnerable populations; Sandblom's (2006) analysis of grief and depression after miscarriage among couples with history of infertility; and Wojnar's (2007) research with lesbian couples who miscarry.

Application of the Theory in Practice In recent decades, Swanson's theory has also been successfully adapted as a framework for professional nursing practice by various universities and practice settings across the United States, Canada, and Sweden. Some examples of Swanson's Caring Theory use in practice have been described in recently published works by Higdon and Shirey (2012); Jennings, Heiner, Hemman, and Swansion (2005); Kavanaugh et al. (2013); Tonges et al. (2014); Tonges and Ray (2011); and Wang and Hsu (2014). A description of these practice examples using Swanson's Caring Theory is

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presented in Table 9.3.

Table 9.3 Examples of Theory in Practice

According to Chinn and Kramer (2004), the situations in which the theories may be applied should not be limited. Clearly, it has been

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demonstrated that Swanson's Theory of Caring may be used effectively to establish therapeutic relationships with diverse populations, far beyond the perinatal context, to promote the individuals' wellness across life span (Swanson, 1999c), making it generalizable to any nurse–client relationship and any clinical setting. Hence, it offers a framework for enhancing contemporary nursing practice while bringing the discipline to its traditional caring–healing roots.

Andershed (2009) conducted a review of literature on the use of the theory in research and practice. She found a total of 120 studies that met the inclusion criteria, 71 published in the United States, 30 in Europe, 9 in Canada, 6 in Australia/New Zealand, 3 in Israel, and 1 in Asia. Most of the articles (97) mentioned the theory in the introduction, theoretical framework, or discussion but did not develop its usefulness to the study. Among the populations that were the focus of research or practice applications included high-risk families, persons suffering from dementia, parents suffering from perinatal loss, nurses learning home infusion therapy administration, African Americans and access to mental health services, AIDS family caregivers, relatives involved in end-of-life care, and critical care nurses. The review revealed the broad application of the theory to research and practice. See Using Middle Range Theory in Practice 9.2.

USING MIDDLE RANGE THEORY IN PRACTICE 9.2

Source: Mellott, J., Richards, K., Tonry, L., Bularzik, A. M. H., & Palmer, M. (2012). Translating caring theory into practice: A relationship-based care experience. Nurse Leader, 10(5), 44–46, 49. doi: 10.1016/mnl.2012.02.006

Problem The chief executive officer in a New Hampshire hospital

“challenged senior leadership to propose innovative strategies for improving organizational excellence” (p. 44).

Intervention A shared governance model emerged that advanced a professional

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culture of nursing. After exploring theoretical frameworks that would promote the desired culture, the Nursing Leadership Council and the chief nurse executive selected Relationship-Based Caring (RBC), Swanson's Theory of Caring. A steering committee was formed, who served as the training team to promote the six dimensions of RBC. They worked to develop guidelines of unit-based practice councils and developed notebooks containing each day's handouts from the training session plus a workbook of additional relevant resources.

Five units were selected with five to six staff members plus the manager participating in the training. The training consisted of four 8- hour sessions. The unit teams were to act as liaisons to the steering committee and be responsible for their unit's education. By day 4 of training, the teams had refined the vision statements: (1) Commitment to Patient and Families, (2) Commitment to Coworkers, and (3) Managers' Commitment to Staff. The teams also developed implementation plans that would promote the actualization of the commitments. They met with the steering committee every 6 weeks for a year following the training.

Outcomes Using a Likert scale, a survey of staff, pre and post the

implementation of RBC, found that its implementation had a positive effect on teamwork and congeniality. Additional units were involved in the training. A website was developed to provide information to staff about ongoing activities and a newsletter was circulated that included information about the RBC initiative. A quarterly Nursing Summit, which is attended by nurse leaders in the organization, is another forum to help maintain the focus and commitment of RBC.

Summary The usefulness of Swanson's Theory of Caring has been demonstrated in research, education, and clinical practice. The belief that caring has a pivotal role in the practice of professional nursing had its beginning in the theorist's clinical practice, in the influence of her mentors, and in the findings from her phenomenological investigations.

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Swanson's (1999a, 1999b, 1999c) later works, including meta- analysis of research on caring, have demonstrated generalizability and applicability of the Theory of Caring in education, clinical nursing practice, and research beyond perinatal context. Nurse caring, as demonstrated by Swanson in research with women who miscarried, caregivers in the NICU, and socially at-risk mothers, recognizes the importance of attending to the wholeness of human experiences and needs.

Critical Thinking Exercises

1. Think about a time when you felt that you or someone close to you experienced caring in the health care environment. What was it like to experience caring? What did the practitioner say or do? How consistent were his or her actions with caring processes identified by Swanson? Alternatively, think about a situation when caring was not delivered. What was missing in your interaction with that practitioner?

2. Think about a situation in your clinical practice when your interaction with the client did not go smoothly. Consider key definitions identified in Swanson's theory and reflect on what caring processes were missing from that interaction. In what ways could that interaction be improved?

3. Consider Swanson's theory of caring as a theoretical framework for a research study relevant to your clinical practice. In what ways would it be applicable?

Resources on Visit http://thePoint.lww.com/Peterson4e for an Analysis of Theory exercise for the theory of Caring.

REFERENCES Andershed, B. (2009). Review of research related to Kristen Swanson's

middle-range theory of caring. Scandinavian Journal of Caring

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http://thePoint.lww.com/Peterson4e

Science, 23, 598–610. doi: 10.111/j.1471-6712,2008.00647.x Boykin, A. (1994). Living a caring-based curriculum. New York, NY:

National League for Nursing. Chinn, P. L., & Kramer, M. K. (2004). Integrated knowledge development

in nursing (6th ed.). St. Louis, MO: Mosby. Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-

Wesley. Benner, P., & Wrubel, J. (1989). The primacy of caring. Menlo Park, CA:

Addison-Wesley. Higdon, K., & Shirey, M. (2012). Implementation of a caring theoretical

framework in a multihospital system. Journal of Nursing Administration, 42(4), 190–194. doi: 10.1097/NNA.0b013e31824ccd64

Jennings, B. M., Heiner, S. L., Hemman, E. A., & Swansion, K. M. (2005). Soldiers' experiences with military health care. Military Medicine, 170(12), 999–1004.

Kavanaugh, K., Moro, T. T., Savage, T., & Mehendale, R. (2006). Enacting a theory of caring to recruit and retain vulnerable participants for sensitive research. Research in Nursing and Health, 29(3), 244–252.

Kavanaugh, K., Roscigno, C. I., Swanson, K. M., Savage, T. A., Kimura, R. E., & Kilpatrick, S. J. (2013). Perinatal palliative care: Parent perceptions of palliative care: Parent perceptions of caring interactions surrounding counseling. Palliative and Supportive Care, 4, 1–11.

Kish, C. P., & Holder, L. M. (1996). Helping to say goodbye: Mergin clinical scholarship with community service. Holistic Nursing Practice, 10(3), 74–82.

Leininger, M. M. (1981). The phenomenon of caring: Importance of research and theoretical considerations. In M. M. Leininger (Ed.), Caring: An essential human need. Thorofare, NJ: Slak.

Leininger, M. M. (1988). Leininger's theory of nursing: Cultural care diversality and universality. Nursing Science Quarterly, 1(4), 152–160.

McNair, D. M., Lorr, M., Droppleman, L. F., & Reynolds, P. D. (1981). A primer of theory construction. Indianapolis, IN: Bobs-Merrill.

Meleis, A. I. (1997). Theoretical nursing: Development and progress. Philadelphia, PA: Lippincott-Raven.

Quinn, J., Smith, M., Ritenbaugh, C., & Swanson, K. M. (2003). Research guidelines for assessing the impact of the healing relationship in clinical nursing. Alternative Therapies, 9(31), 69–79.

Raynolds, P. D. (1971). A primer of theory construction. Indianapolis, IN:

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Bobbs-Merril. Sandblom, S. (2006). Does a history of infertility affect the grief and

depression response in couples experiencing a spontaneous miscarriage? (Unpublished Master Thesis). University of Washington School of Nursing.

Sikma, S. (2006). Staff perceptions of caring: The importance of a supportive environment. Journal of Gerontological Nursing, 32(6), 22–29.

Swanson, K. M. (1990). Providing care in the NICU: Sometimes an act of love. Advances in Nursing Science, 13(1), 60–73.

Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166.

Swanson, K. M. (1993). Nursing as informed caring for the well-being of others. Image: Journal of Nursing Scholarship, 25(4), 352–357.

Swanson K. M. (1998). Caring made visible. Creative Nursing Journal, 4(4), 8–11, 16.

Swanson, K. M. (1999a). Research-based practice with women who have had miscarriages. Image: Journal of Nursing Scholarship, 31(4), 339–345.

Swanson, K. M. (1999b). The effects of caring, measurement, and time on miscarriage impact and women's well-being in the first year subsequent to loss. Nursing Research, 48(6), 288–298.

Swanson, K. M. (1999c). What's known about caring in nursing: A literary meta-analysis. In A. S. Hinshaw, J. Shaver, & S. Feetham (Eds.), Handbook of clinical nursing research (pp. 31–60). Thousand Oaks, CA: Sage.

Swanson, K. M. (2000). Predicting depressive symptoms after miscarriage: A path analysis based on Lazarus' paradigm. Journal of Women's Health and Gender-Based Medicine, 9(2), 191–206.

Swanson, K. M. (2001). A program of research on caring. In M. E. Parker (Ed.), Nursing Theories and Nursing Practice (pp. 411–420). Philadelphia, PA: Davis.

Swanson, K. M. (2002). Caring Professional Scale. In J. Watson (Ed.), Assessing and measuring caring in nursing and health science. New York, NY: Springer Publishing Company.

Swanson, K. M. Chen, H., Graham, J. C., Wojnar, D. M., & Petras, A. (2009). Resolution of depression and grief during the first year after miscarriage: A randomized controlled trial of couples-focused interventions. Journal of Women's Health, 18(8), 1245–1257.

Swanson, K. M., Jolley, S. N., Pettinato, M., Wang, T., & Connor, S.

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(2007). The context and evolution of women's responses to miscarriage over the first year after loss. Research in Nursing and Health, 30(1), 2–16.

Swanson, K. M., Karmali, Z., Powell, S., & Pulvermahker, F. (2003). Miscarriage effects on interpersonal and sexual relationships during the first year after loss: Women's perceptions. Journal of Psychosomatic Medicine, 65(5), 902–910.

Swanson, K.M., & Wojnar, D. (2004). Optimal healing environments in Nursing. Alternative Therapies in Health and Medicine, 10(1), 43–51.

Swanson-Kauffman, K. M. (1985). Miscarriage: A new understanding of the mother's experience. Proceedings of the 50th anniversary celebration of the University of Pennsylvania School of Nursing, 63–78.

Swanson-Kauffman, K. M. (1986). Caring in the instance of unexpected early pregnancy loss. Topics in Clinical Nursing, 8(2), 37–46.

Swanson-Kauffman, K. M. (1988a). The caring needs of women who miscarry. In M. M. Leininger (Ed.), Care, discovery and uses in clinical and community nursing (pp. 55–71). Detroit, MI: Wayne State University Press.

Swanson-Kauffman, K. M. (1988b). There should have been two: Nursing care of parents experiencing the perinatal death of a twin. Journal of Perinatal and Neonatal Nursing, 2(2), 78–86.

Swanson-Kauffman, K. M., & Roberts, J. (1990). Caring in parent and child nursing. In Knowledge about care and caring: State of the art and future development. Washington, DC: American Academy of Nursing.

Tonges, M., McCann, M., & Strickler, J. (2014). Translating caring theory across the continuum from inpatient to ambulatory care. Journal of Nursing Administration, 44(6), 326–332. doi: 10.1097/NNA.0000000000000077

Tonges, M., & Ray, J. (2011). Translating caring theory into practice: the Carolina Care Model. Journal of Nursing Administration, 4(19), 374–381. doi: 10.1097/NNA.0b013e31822a732c

Wang, W. P., & Hsu, H. T. (2014). Applying Swanson's caring theory to manage spiritual distress in a patient with terminal lung cancer. Li Hu Zi: The Journal of Nursing, 61(4), 97–102. doi: 10.6224/JN.61.4.97

Watson, J. (1979). Nursing: The philosophy and science of caring. Boston, MA: Little & Brown.

Watson, J. (1988). New dimensions of human caring theory. Nursing Science Quarterly, 1, 175–181.

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Watson, J. (1999). Nursing: Human science and human care: A theory of nursing. Sudbury, MA: Jones & Barlett.

Wojnar, D. (2007). Miscarriage experiences of lesbian birth and social mothers: Couples' perspective. Journal of Midwifery and Women's Health, 52(5), 479–485.

Yorkston, K. M., Klasner, E. R., & Swanson, K. M. (2001). Communication in multiple sclerosis: Understanding the insider's perspective. American Journal of Speech Language Pathology, 10, 126–137.

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10 Interpersonal Relations

Sandra J. Peterson

Definition of Key Terms

Communication A skill necessary to understand the nurse– patient relationship; composed of “spoken language, rational and nonrational expressions of wishes, needs, and desires, and the body gesture” (Peplau, 1991, p. 289).

Interpersonal relations Any process that occurs between two people. The interpersonal processes between nurse and patient are identified as the core of nursing (Forchuk, 1993).

Nursing situation What occurs between the nurse and the patient; thus the interaction of the individual thoughts, feelings, and actions of both.

Observation A skill necessary to understand the nurse–patient relationship. Its aim, “as an interpersonal process, is the identification, clarification, and verification of impressions about the interactive drama, of the pushes and pulls in the relationship between nurse and patient as they occur” (Peplau, 1991, p. 263).

Personality “… Pattern that is relatively stable and that characterizes persisting situations in the life of an individual … total assets and liabilities that determine an individual action” (Peplau,

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1991, pp. 164, 165). Nurses attempt to provide experiences for patients that promote personality development.

Phases of nurse–patient relationship Four overlapping but generally sequential aspects of the relationship identified as orientation, identification, exploitation, and resolution.

Psychobiological experiences Factors that influence the functioning of personalities, providing energy that is converted into constructive or destructive behavior. The primary source of this energy is anxiety.

Psychological tasks “Tasks encountered in the process of learning to live with people as an aspect of formation and development of personality and as an aspect of the tasks demanded of nurses in their relations with patients” (Peplau, 1991, p. 159), for example, counting on others, delaying satisfaction, identifying self, and participating with others.

Recording Methods used to create documents of nurse–patient interactions, primarily for the purpose of student learning.

Roles in nursing Set of functions that nurses use in the context of nurse–patient situations as a means of helping the patient, identified as stranger, resource person, teacher, leader, surrogate, and counselor.

Introduction “When the history of nursing theory comes to be written few names will be seen to have been more influential than that of Hildegard Peplau” (Welch, 1995, p. 53). Peplau, who developed the theory of interpersonal relations, is identified as the first contemporary nurse theorist (McKenna, 1997). Sills (1978) credits Peplau with clarifying the relationships between nursing theory, practice, and research. “Theory was used to guide nursing practice. Theory was tested in the real world of practice” (Sills, 1978, p. 122).

Although Peplau entitled her work a conceptual frame of reference,

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she also referred to it as a theory (Peplau, 1992, p. 13). Peplau produced a testable theory, identifying her work as a “source of hypotheses that may be examined with profit in all nursing situations” (Peplau, 1991, p. ix). The theory of interpersonal relations is currently labeled as a middle range theory (Armstrong & Kelly, 1995; Fawcett, 2000; O'Toole & Welt, 1989). Peplau, herself, defined the scope of her theory as in the middle range. She referred to it as “a partial theory for the practice of nursing as an interpersonal process” (Peplau, 1991, p. 261).

Initially developed with a focus on phenomena of most concern to psychiatric nurses, the theory of interpersonal relations is applicable to all nurses (Peplau, 1964, 1992). Peplau (1997) claimed that “the nurse–patient relationship is the primary human contact that is central in a fundamental way to providing nursing care” (p. 163). The stated purpose of her theory is the improvement of nurses' relations with patients. This is achieved through the nurse's understanding of his or her own behavior, helping others identify personally experienced difficulties, and applying principles of human relations to the problems that arise in the context of relationships (Peplau, 1991, p. xi). This process results in a nursing situation in which both the patient and the nurse learn and grow. A growth-producing relationship with others is a goal that transcends any particular nursing specialty, and in her description of the theory, Peplau (1952, 1991) used examples of patients with a variety of health issues, for example, a woman diagnosed with lymphosarcoma, a child having surgery on his hand to correct a congenital problem, a woman in labor, and a man with a coronary occlusion.

Historical Background What makes Peplau's theory of interpersonal relations so remarkable is that it was conceived during a period in nursing's history when nurses had little or no independent role and little or no investment in the development of nursing theory. Peplau was educated and began her nursing practice, as described in her own words, at a time when “we were absolutely not allowed to talk to a patient, because if we did we might say the wrong thing” (Welch, 1995, p. 54). It was not until the late 1930s while working as a staff nurse at Mount Sinai Hospital, New York, that she discovered “there was more to nursing than just this doing activity, because there we were allowed to talk to the patients” (Welch, 1995, p. 54). In the 1940s,

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Peplau found psychiatric nursing still focused on activities, for example, helping patients with tasks of daily living, which included cleaning patients' rooms and doing patients' laundry (Peplau, 1985, p. 31). It was out of her desire to be more useful to patients that the idea of interpersonal relations theory was developed.

Peplau used both deductive and inductive methods in her theory development work (Reed, 1995). Deductively, she integrated ideas from a number of theories into her theory of interpersonal relations. She was influenced by the work of Sigmund Freud, particularly his interest in unconscious motivation. Harry S. Sullivan's theory of interpersonal relations also contributed to her thinking about interpersonal processes in nursing. For example, she refers to his concepts of anxiety, self-system, and modes of experiencing. Also incorporated into her theory are elements from developmental psychology and learning theory (Armstrong & Kelly, 1995; Lego, 1980) and the ideas of the humanistic psychologists, Abraham Maslow, Rollo May, and Carl Rogers (Gastmans, 1998).

Peplau defined her inductive approach in both general and specific terms. The inductive approach for concept naming that she described included several steps:

1. Observing behaviors for which no explanatory concepts are available 2. Seeking to repeat those observations in others, under similar

conditions 3. Noting regularities concerning the nature of the data being observed 4. Naming the phenomena (Peplau, 1989, p. 28)

These steps would be followed by further observation, resulting in the phenomenon becoming more clearly defined, which then allowed for testing with additional patients. “Eventually, useful interventions would be derived from the explanation of the phenomenon and the effects of these interventions upon it also tested” (Peplau, 1969, p. 28).

Peplau's specific inductive process of theory development involved using data from student–patient interactions. “I just happened to hit upon the notion of sitting students down with one patient for a long time and then study what they did with patients” (Peplau, 1985, p. 31). It was from these observations that psychotherapy by nurses in the context of the interpersonal relationship emerged.

Her theory of interpersonal relations, first appearing in 1952 in the book Interpersonal Relations in Nursing, has been published unchanged

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several times. During the 1950s and 1960s, her theory was used and tested in the challenging environment of state psychiatric hospitals. Some of this work is reported in Basic Principles of Patient Counseling published in 1964 by Smith, Kline, and French (Sills, 1978, p. 124). In four decades since its inception, interpersonal theory has been expanded by Peplau and other nurse scientists (Peplau, 1991, p. vi). For example, work on therapeutic milieu, crisis, and family therapy has been based on Peplau's theory. Sills (1978) conducted a review of three major nursing journals from 1972 to 1977 (one published for the first time in 1963). She identified 93 citations of Peplau's work and concluded that “it [is] remarkable that twenty-five years after the publication of Interpersonal Relations in Nursing that it, with no revisions, is still found useful. And … that utilization increases” (Sills, 1978, p. 125).

Definitions of Theory Concepts Although not specified at the time of the development of the theory in 1952, each domain of the traditional metaparadigm of nursing is addressed by Peplau. Her definitions of these major domain concepts are useful in understanding the rather complex theory of interpersonal relations.

Nursing The foundation of her theory is her definition of nursing. Perhaps what is unique, but not unexpectedly so, is the primacy of the nurse–patient relationship in her definition. She defines nursing as an interpersonal process, intended to be therapeutic. It “is a human relationship between an individual who is sick or in need of health services” (Peplau, 1991, pp. 5, 6) and a nurse who has appropriate preparation to respond to the need. The use of technical procedures in nursing is acknowledged but relegated to a secondary role. Her most frequently quoted definition is as follows:

Nursing is a significant, therapeutic, interpersonal process. It functions co-operatively with other human processes that make health possible for individuals in communities.…Nursing is an educative instrument, a maturing force, that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and

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community living. (Peplau, 1952, p. 16)

Persons In her theory, Peplau includes two persons as components: the nurse and the client or, more often, the patient (O'Toole & Welt, 1989; Peplau, 1992). Peplau (1952) initially defined man as:

An organism that lives in an unstable equilibrium (i.e., physiological, psychological, and social fluidity) and life is the process of striving in the direction of stable equilibrium, i.e. a fixed pattern that is never reached except in death. (p. 82)

Forchuk (1991) revised that definition, omitting the terms “organism” and “equilibrium” because they represent a more “mechanical, closed-system perspective” (p. 55) that is inconsistent with Peplau's view of humans as growth seeking. A person is a relational being experiencing “interacting expectations, conceptions, wishes, and desires, as well as feelings when … in situations with other persons” (O'Toole & Welt, 1989, p. 5). This perspective on persons as relational beings is fundamental to the theory.

Nurse The nurse is identified as a professional with definable expertise (Peplau, 1992). This expertise should include the ability to “identify human problems that confront patients, the degrees of skill used to meet situations, and be able to develop with patients the kind of relationships that will be conducive to improvement in skill” (Peplau, 1991, p. xiii). The nurse also possesses “a unique blend of ideals, values, integrity, and commitment to the well-being of others” (Peplau, 1988, p. 10).

Patient The patient is defined first as a person, deserving of “all of the humane considerations: respect, dignity, privacy, confidentiality, and ethical care” (Peplau, 1992, p. 14), but a person who has problems that now require the services of a nurse. Ideally, the patient participates actively in the nurse–

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patient relationship (O'Toole & Welt, 1989, p. 57).

Health Peplau (1952) provided a definition of health in her initial description of the theory. “It [health] is a word symbol that implies forward movement of personality and other human processes in the direction of creative, constructive, productive, personal, and community living” (p. 12). In addition, she identified two processes that are necessary for health: (a) biological, for example, absorption and elimination, and (b) social, which promotes physical, emotional, and social well-being (pp. 12–13).

Environment Peplau focused on the issue of environment as milieu, using the term to describe a therapeutic environment (O'Toole & Welt, 1989, p. 78). The milieu is composed of structured (e.g., ward government) and unstructured components. The unstructured components consist of the complex relationships between patients, staff, visitors, and other patients, which are often neglected and yet have a significant impact on patient outcomes. Milieu ideally involves the creation of an atmosphere conducive to recovery.

Description of Theory of Interpersonal Relations Peplau implied a philosophical foundation to her theory of interpersonal relations and provided two basic assumptions, which have been expanded by others, using the initial publication of the theory as the primary source. Peplau did not label the propositional statements in her theory as such; instead, they are integrated into her discussion of the components of the theory.

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Philosophical Foundations There are some different perspectives on the nature of the philosophical underpinnings of Peplau's theory of interpersonal relations in nursing. Sellers (1991) labels the theory:

… a mechanistic, deterministic, persistence ontological view; an epistemology that is consistent with the totality paradigm, with its emphasis on a received view of knowledge and logical positivism; and an axiology that values stability, traditionalism, and nursing's close alignment with medicine. (p. 158)

Sellers did not support these conclusions with examples from the theory. Since the complexity of Peplau's theory makes it difficult to categorize, it is not surprising that others have considered it from a different philosophical perspective.

More recently, existential phenomenology has been identified as the philosophical foundation of Peplau's theory (Gastmans, 1998). Consistent with phenomenology, observation of patients as a fundamental task of nursing is seen as contextual and value laden. It requires openness to and involvement with patients' existential situations. “Nursing has a human interpretive character” (Gastmans, 1998, Phenomenology and Nursing Science, para. 5) with the nurse–patient relationship at its core. Interpretations are meaning-seeking activities that arise as the nurse participates with the patient. This participation with the patient is described as respectful, communicating positive interest, and nonjudgmental regard (Peplau, 1991). Peplau uses the term “professional closeness” (Peplau, 1969) to summarize these characteristics that allow the nurse to communicate care when participating with patients.

Although most of Peplau's philosophy is imbedded in her writings, she does delineate six “beliefs about patients” (Peplau, 1964). She identifies these as her “philosophy about patients and their care” (p. 30), attributed primarily to psychiatric nurses but applicable to all patients:

1. All behavior is purposeful, has meaning, and can be understood. 2. The nurse must observe what is going on; she must interpret what is

observed, and then she must decide action on the basis of her interpretations.

3. The nurse meets the needs of the patient.

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4. The nurse–patient interaction—the verbal and nonverbal exchanges in the nursing situation—can influence recovery.

5. The personality of the patient is somehow involved in his illness. 6. There are some ideas about nursing care that relate to the word anxiety

(pp. 30–35).

Assumptions In the initial publication of her theory, Peplau (1952) listed two guiding assumptions, emphasizing the importance of the nurse's own growth and development in establishing helpful interpersonal relationships with patients. Others have expanded that list through personal correspondence with Peplau and review of her writings. Table 10.1 provides a list of the assumptions of the theory of interpersonal relations.

Table 10.1 Assumptions of the Theory of Interpersonal Relations

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These 13 assumptions serve to illustrate the complexity of Peplau's theory of interpersonal relations.

Theory Description with Propositional Statements The core of the theory, the relationship between nurse and patient, is composed of phases, fulfilled through roles, influenced by psychobiological experiences, and requires attending to certain psychological tasks. Peplau also identified methods that can assist the nurse to develop understanding of the nurse–patient relationship. The description of the theory is presented using the same sequence as Peplau (1952, 1991) did in her seminal work, Interpersonal Relations in Nursing.

Composed of Phases Peplau (1991) initially defined four phases of the nurse–patient relationship: orientation, identification, exploitation, and resolution. Forchuk (1991) later reconceptualized these phases into three, with the working phase replacing the identification and exploitation phases. These phases are considered overlapping and interlocking, with each phase possessing characteristic functions. They are experienced in every nursing situation.

Phase of Orientation There are four functions that nurses use during orientation: (1) provide the resources of specific, needed information to help the patient understand the problem and the health care situation; (2) serve as a counselor to encourage the patient to express thoughts and feelings related to the problem situation; (3) act as surrogate to family members so that the patient can reenact and examine relevant issues from prior relationships; and (4) use technical expertise to attend to concerns or issues that require the use of professional devices. These nursing functions assist the patient to address the needs experienced during the phase of orientation.

The patient needs to recognize and understand the extent of the difficulty and the help that is needed to address it. Orienting the patient to

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the nature of the problem requires that the nurse acts as both a resource person and a counselor. As a resource person, the nurse provides specific information about the problem confronting the patient and helps the patient see the personal relevance of the information. As a counselor, the nurse encourages the patient to be actively involved in identifying and assessing the problem.

The patient also needs to recognize and use the professional services offered. The nurse serves as a resource person to help the patient identify the range and limitations of services provided. It is important for the patient to know what can be expected from the nurse. In order for the patient to move successfully to the next phase in the nurse–patient relationship, he or she must harness the energy from the tension and anxiety created by felt needs in a constructive fashion to define, understand, and resolve the problem. The counseling role of the nurse is vital in dealing with the patient's anxiety. The nurse must understand the meaning of the situation to the patient and be alert to evidence of anxiety manifested by apathy, dependency, or overaggressiveness or terror and panic if the patient fails to deal with it. As a resource person, the nurse helps the patient understand the meaning of the anxiety-promoting events he or she is experiencing in the health care environment. In the counseling role, the nurse encourages the expression of expectations and feelings by responding unconditionally to the patient. This is accomplished through nondirective listening, encouraging the patient to focus on the problem and express related feelings, without offering advice, reassurance, suggestions, or persuasions. This establishes the foundation for the work of the next phase of the relationship.

Phase of Identification During this phase, the patient can selectively begin to identify with some of the individuals who are offering help in one of the three ways: with interdependence/participation, independence/isolation, or dependence/helplessness. This identification is based on the degree to which the patient believes the nurse will be helpful and on the nature of his or her past relationships.

The patient who responds interdependently feels less powerless and identifies with and expresses the attitudes of cheerfulness, optimism, and problem solving that he or she perceives in the nurse. Under these conditions, the patient may express feelings that are not normally

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considered acceptable (e.g., helplessness or self-centeredness). These expressions are seen as potentially growth producing if the nurse accepts the feelings and continues to meet the needs of the patient.

Not all patients can identify with the nurse offering help because of the influence of earlier negative relationships with others. This experience often leads to a response that is independent or isolative. At this time, the nurse in the surrogate family member role may provide the patient with the opportunity to have new and more positive relational experiences.

Other patients may identify with the nurse too quickly, which can result in an overly dependent response to the nurse. These patients want all their needs to be met by others with no expectations placed on them. This not uncommon response limits the possibility of growth through the experience.

It is important for the nurse to consider the phenomenon of leadership during the identification phase. The nurse attempts to provide opportunities for the patient to assume responsibility in the situation that promotes more constructive rather than imitative learning. The patient is encouraged to develop the skills to perceive, focus, and interpret cues in the situation, and then respond appropriately, independent of the nurse.

Phase of Exploitation During this phase, the patient feels comfortable enough to take full advantage of the services being offered and experience full value from the relationship with the nurse. Varying degrees of dependence and self- directedness are manifested with vacillation between the states. Ideally, the patient begins to identify and orient self to new goals besides solving the immediate problem, for example, in the case of a hospitalized patient, the goal of functioning at home.

Phase of Resolution As old needs are met, they are replaced by new goals that began to be formulated while the patient engaged in (i.e., exploited) the use of the services provided by the nurse. It is hoped that the patient will experience a sense of security and release that occurs because he or she received help in the time of need. This security is accompanied by less reliance on and decreasing identification with helping persons and increasing reliance on self to deal with the problem. This is the result of a nurse–patient

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relationship that is characterized during all phases by (1) an unconditional, patient-focused, and ongoing relationship that provides for the patient's needs; (2) a recognition of and appropriate response to cues that indicate the patient's desire and readiness to grow; and (3) a shift of power from nurse to patient as patient assumes responsibility for achieving new goals (Peplau, 1991, pp. 40, 41).

Fulfilled Through Roles The roles of nursing are defined by nurses, endorsed by patients, influenced by society, and promoted by the professional literature. Peplau identified the roles that she considered most relevant to nurse–patient situations and delineated principles for the successful fulfilling of those roles. The roles she identified were as follows:

1. Stranger: The nurse approaches the patient with respect and positive interest.

2. Resource person: The nurse answers questions using level of functioning, psychological readiness, psychological atmosphere, and relevance of the questions to formulate the response.

3. Teacher: The nurse considers what patients already know and level of interest to develop learning situations that enable patients to learn through experience.

4. Leader: The nurse engages patients as active participants in planning their care.

5. Surrogate: The nurse recognizes that patients often respond to him or her as they would to a person from their past and uses that recognition to help patients deal constructively with their feelings and learn new ways or relating to others.

6. Counselor: The nurse observes and listens to patients in a way that helps patients develop fully understanding of themselves, their feelings, and actions.

Influenced by Psychobiological Experiences The psychobiological experiences of needs, frustration, conflict, and anxiety influence the functioning of personalities. These experiences are also sources of energy that can result in both constructive and destructive actions. It is through understanding these experiences that individuals can

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learn to become more productive human beings (Peplau, 1991).

Needs Although Peplau identifies needs as both physiological and psychological, her emphasis is on those that are psychological in nature. Security, new experiences, affection, recognition, and mastery are identified as psychological needs. If needs are unmet they lead to increasing tension or anxiety. When needs are met, new and more health-producing ones may emerge.

Frustration Frustration occurs when fulfillment of a need or pursuit of a goal is blocked. The primary goal identified by Peplau (1991) is the need for a “feeling of satisfaction and/or security” (p. 86). Frustration can be manifested as aggression and/or anxiety. The individual defends self from anxiety by (1) modifying the goal to one for which success is more likely, (2) giving up on the goal with the possibility of dissociation of feelings occurring, and/or (3) adopting fixed responses (e.g., stereotyping and delusions). It is important for the nurse and patient to communicate to clarify goals and arrive at some mutually acceptable ones.

Conflict Another issue that the nurse and patient deal with in their interpersonal relationship is conflicting goals. Conflicting goals are often unrecognized and are expressed in the behavioral responses of hesitation, tension, vacillation, or complete blocking.

Blocking occurs when approaching a goal is completely incompatible with avoiding another one (approach–avoidance conflict). The most common example is the desire to go home (approaching goal) that coexists with the desire to not leave the perceived safety of the hospital (avoiding goal). Fear results and can express itself as withdrawal or avoidance. If that which is feared can be identified, the nurse can act as a resource person by providing information and experiences that can reduce the strength of avoidance. Individuals often are required to make choices between two desirable goals (approach–approach conflict). The nurse is most helpful by fulfilling the counselor role in this situation. Listening in a way that encourages the expression of feelings allows the individual to

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recognize the factors that influence the choice to be made.

Unexplained Discomfort/Anxiety As previously noted, anxiety or unexplained discomfort, as Peplau sometimes referred to it, can occur when there are unmet needs, obstacles to goals, or conflicting goals. Anxiety is often associated with guilt, doubt, fears, and obsessions. Both patients and nurses experience this feeling state that influences behavior productively or destructively through the energy it produces. The nurse helps reduce the anxiety to a more manageable and useful level by his or her presence as someone who will listen and provide for the patient's physical needs.

Requires Attending to Certain Psychological Tasks Psychological tasks are those related to learning to live with others. Peplau addresses the tasks of (1) learning to count on others, (2) learning to delay satisfaction, (3) identifying oneself, and (4) developing skills in participation. These tasks occur not only as an aspect of the development of personality but also as features of nurse–patient relationships. During this relationship, the nurse has the opportunity to help patients develop in areas of task deficit. In order to provide this assistance, the nurse uses the previously discussed roles and understanding of the previously examined psychobiological experiences. In addition, in order to understand his or her own personality and the patient's, the nurse needs to appreciate the psychological tasks of infants and children as identified by Sigmund Freud and Richard Havighurst (Peplau, 1991, p. 166) and the acculturation processes that enable those tasks to be successfully completed.

Counting on Others The first psychological task of the infant is the development of healthy dependence. The nurse encounters varying degrees of both healthy dependency and dependency longings in nursing situations. In response to those situations, nurses help patients learn that they are trustworthy and then assist patients to become more aware of their needs and to express those needs more effectively (Peplau, 1991, p. 181). There are a number of positive consequences of having needs met. The patient experiences a

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feeling of self-worth and as a result begins to collaborate with the nurse in his or her growth. In addition, as needs are met, new, more mature ones can emerge.

Delaying Satisfaction The socialization of a child includes the lesson of deferring to the wishes of others and delaying gratification of his own wishes, a lesson that is dependent on having already learned that those being deferred to are also those that can also be counted upon. According to Peplau (1991), this lesson takes place primarily during the process of toilet training.

Peplau (1991) identified principles that are consistent with healthy toilet training and general socialization activities that help the nurse establish rapport with patients and assist them in developing the ability to delay gratification of needs:

1. Show unconditional interest and acceptance. 2. Encourage expression of needs and feelings. 3. Provide times in which demands are met and they are not met. 4. Promote participation in decision making so that patients can become

more self-directing. 5. Allow for some “hoarding,” which reinforces feelings of security. 6. Encourage sharing, which can only occur when there is freedom from

coercion.

Hopefully, patients learn that delaying gratification can be experienced without an overwhelming sense of anxiety.

Identifying Oneself Self-identity or concept of self enhances or distorts relationships with others, a fact that is true for both the patient and the nurse. This sense of self develops initially through a child's interactions with adults as he or she learns to rely on others and delay gratification in relation to needs. The way the child is appraised during these interactions results in three possible views of self: (1) a sense of competency to identify wants and needs, (2) a sense of helplessness and dependence on others, and (3) a sense of distrust in others. A nurse can assist a patient struggling with self- concept by:

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1. Being value neutral, “… providing merely conditions and acting as a sounding board against which the patient may air his views and give full expression to his feelings in a nonjudgmental relationship” (Peplau, 1991, p. 226)

2. Communicating hope and acceptance 3. Avoiding the problematic responses of praise, blame, and indifference

The nurse who exhibits these characteristics can enhance the patient's whole concept of self and ability to experience interdependent relationships with others.

Participating with Others When individuals participate in making decisions that affect them, they are more likely to understand the decisions, be involved in implementing them, and appreciate the contributions of others to the ultimate decision. This task of participating with others is composed of the abilities to compromise, compete, and cooperate. The nurse attempts to encourage participation with others through collaboration with the patient in addressing problems. This participatory approach serves to improve the patient's skills in meeting problems. Peplau (1991) describes a three-step process:

1. Assist the patient to identify the problem. 2. Collaborate to “achieve a decision on what is possible, what can be

done, and then move into other items that have been mentioned and other possible courses of action that can be taken in behalf of and with the co-operation of the patient” (Peplau, 1991, p. 248).

3. Encourage the patient to try out what has been proposed.

Nursing Methods Used to Understand Interpersonal Processes Observation, communication, and recording are three basic skills that are “valuable to the use of nursing as an interpersonal process that is therapeutic and educative for patients” (Peplau, 1991, p. 309). Peplau considered these three operations as integral to the nursing process.

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Observation “The aim of observation in nursing, when it is viewed as an interpersonal process, is the identification, clarification, and verification of impressions about the interactive drama, of the pushes and pulls in the relationship between nurse and patient, as they occur” (Peplau, 1991, p. 263). Observation as described by Peplau is composed of four components: (a) intuitive impressions or hunches, (b) hypothesis statements, (c) organized observations based on the hypothesis, and (d) judgment formations.

Peplau (1991) provides a classification of types of observer–observed relationships that the nurse can use to gather evidence:

1. Spectator: The patient is unaware of being observed. The nurse is generally engaged in another activity while observing the patient.

2. Interviewer: The patient is aware of being observed as he or she responds to the situation or to the directive or nondirective questioning of the nurse. The nurse frequently takes notes while observing as an interviewer.

3. Collector: The nurse uses records and reports created by others as a way of determining what has happened in a particular situation. Observations made using this approach can help form partial impressions.

4. Participant: “The nurse engages in ordinary activities connected with nursing a patient and at the same time observes the relationship between the patient and herself” (Peplau, 1991, p. 274). The patient is aware that nursing care is being given but is unaware that his/her responses are being observed. The observations need to be organized, and once organized, they can serve as the basis of making nursing judgments and designing experiences that help patients solve problems.

Communication One of the basic tools of nursing is communication, which requires “awareness of means of communication; spoken language, rational and nonrational expressions of wishes, needs, and desires, and the body gesture” (Peplau, 1991, p. 289). Use of words or verbal communication can convey facts, focus on everyday events, and provide interpretations. Spoken language can reveal personal realities or express hidden meanings, but it can also avoid conveying anything meaningful.

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There are two main principles for effective verbal communication: clarity and continuity. Clarity occurs when there is a common frame of reference or when specific efforts are made to arrive at mutual understanding. Continuity occurs when the connections between ideas and the related feelings, events, or themes expressed through the ideas are made evident. Following up on what patients say communicates that what they said is important and that as individuals they are worthwhile.

The nurse's self-awareness is one of the primary conditions for achieving understanding. For a nurse, this awareness enables her to express congruence in the use of words, their relevance, and related actions. Awareness provides the primary distinction between rational and nonrational communications. Rational expressions more likely occur when individuals see themselves rather than others as a source of personal security and when they are oriented toward the future rather than oriented to the past. Nonrational expressions communicate in more ambiguous and indirect ways than do rational expressions. It is the nurse's responsibility to interpret the meaning of the communication by considering the symbols being used to express the underlying emotions.

In addition to the spoken word, gestures can be considered either rational or nonrational expressions. “The body as a whole, as well as parts of it, act as expressional instruments that communicate to others the feelings, wishes, and aspirations of an individual” (Peplau, 1991, p. 304). Underactivity and overactivity are examples of whole-body gestures. Hand gestures (e.g., clenched fist) and facial grimaces (e.g., biting a lip) are examples of more specific gestures. The nurse's responsibility is to observe gestures and attempt to understand both what he or she and the patient are communicating to each other. Arriving at understanding or meaning is a complicated and ongoing process of observation and communication.

Recording Peplau focuses primarily on recording for the purpose of student learning. In addition to charting in medical records, students need additional forms that provide a means of examining the relationship. The purpose is to achieve insight into the student nurse's own behavior and the ways the patients responded. The ultimate goal of recordings, as well as observation and communication, is nurse–patient relationships that result in improved health outcomes for the patient.

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Applications of the Theory: Research Peplau's theory of interpersonal relations remains relevant as a foundation for scientific inquiry and nursing practice. A review of the literature, 2000 to 2010, revealed over 120 publications in which Peplau's work was cited. Theory of interpersonal relations is of interest internationally, with publications by nurse scientists from Australia, Brazil, Canada, China, Denmark, Ethiopia, France, Great Britain, New Zealand, Norway, Slovenia, South Africa, Spain, Sweden, and Turkey. Among the citations to Peplau's work are her biography (Callaway, 2002), book chapters on her theory (Butts & Rich, 2015; George, 2011; Parker & Smith, 2010), editorials and tributes (Wills, 2010; Zauszniewski, 2009), doctoral dissertations (Falk, 2013), and numerous articles using her theory as a framework for research or a basis for nursing care practices. In addition, there are articles that describe her theory (McCarthy & Aquino-Russell, 2009) and present her contributions from historical perspectives (Boling, 2003; Silverstein, 2008).

The theory has served as a framework for studying a variety of research questions, using both qualitative and quantitative methods. Although originally a theory designed to describe therapeutic relationships between nurses and psychiatric patients (Forchuk & Reynolds, 2001; Forchuk et al., 2000; Tofthagen, 2004), it is currently used to examine the nature of relationships with other populations. For instance, in qualitative research focusing on nursing practice, the theory has provided the framework to study (1) role of psychosocial nurses in caring for patients with cancer (Arving, 2011); (2) development of confidence in communication with patients (Gallagher-Lepack, Scheibel, & Gibson, 2009); (3) helping roles in working with survivors of sexual violence (Courey, Martsolf, Drauker, & Strickland, 2008); (4) home-visiting programs for vulnerable prenatal families (McNaughton, 2005); (5) behaviors used by hospitalized patients to engage nurses in interactions (Shatell, 2005); and (6) promoting wellness in young adults experiencing early stages of psychosis (McCann & Baker, 2001). Peplau's theory has also served as the conceptual framework for qualitative research that focused on nursing education, for example, Reid et al.'s (2014) study of simulation to teach interpersonal skills for working with children. In addition, a case study that was qualitative in nature examined the nurse– patient relationship in counseling male patients with acquired immune

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deficiency syndrome (AIDS) (Gautier, 2000). The quantitative studies focus on both nursing practice and nursing

education. New to the body of research are several randomized control studies. Table 10.2 provides examples of nursing research using quantitative methods published in English from 2004 to 2014.

Table 10.2 Examples of Research Using Theory of Interpersonal Relations

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As noted in the table, nurse scientists have begun to explore the usefulness of Peplau's theory in cross-cultural contexts. Using Middle Range Theory in Research 10.1 describes one such study.

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USING MIDDLE RANGE THEORY IN RESEARCH 10.1

Source: Beeber, L. S., Holditch-Davis, D., Perreria, K., Schwartz, T. A., Lewis, V., Blanchard, H., …, Goldman, B. D., et al . (2010). Short-term in-home intervention reduces depressive symptoms in early Head Start Latina mothers of infants and toddlers. Research in Nursing and Health, 33(1), 60–76. doi: 10.1002/nur.20363

Purpose/Research Question The purpose of the study was to test the effect of an intervention

based on Peplau's theory of interpersonal relations on depressive symptoms of Latina mothers of infants and toddlers. Hypothesis 1 stated: “mothers who received the intervention would demonstrate significantly less depressive symptom severity, report less child behavioral aggression and fewer concerns about child social-emotional functioning, and demonstrate greater maternal responsiveness midway through the intervention (T2: 14 weeks), at the conclusion of the intervention (T3: 22 weeks), and 1 month following completion of the intervention (T4: 26 weeks) compared to mothers who received usual care” (p. 62).

Research Design Experimental (pretest/posttest).

Sample/Participants The sample comprised 80 newly immigrated, Latina mothers with

depressive symptoms who had infants or toddlers. They were recruited for Early Head Start programs located in southeastern United States. The mothers spoke only Spanish or had limited English proficiency.

Data Collection Peplau's theory provided the structure for the intervention that

consisted of 16 in-home contacts made by teams of English-speaking master's prepared psychiatric nurses and trained Spanish language interpreters. The focuses of the intervention were (1) reduction of depressive symptoms and their interpersonal sources, (2) choice and use

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of social support, (3) management of stressful life issues and interpersonal disputes, and (4) development of strategies to increase responsiveness to the child. The CES-D, Spanish version, was used to determine depressive symptoms; child aggression was measured by the Child Behavior Checklist (CBCL), Spanish version, and the Ages and Stages Questionnaire—Social–Emotional (ASQ-SE); and responsiveness to child was assessed using the Maternal–Child Observation (MCO) and the Home Observation for Measurement of the Environment (HOME).

Findings The findings were supportive of Peplau's theory:

1. There was a statistically significant greater decrease in depressive symptoms for the mothers receiving the intervention than those who received usual care, T2: p = 0.02, T3: p = 0.01, and T4: p = 0.02.

2. Reports of aggression decreased in the intervention group from T1 to T4 (p = 0.03), whereas they increased in the usual care group during the same timeframe.

3. There were no statistically significant differences between the two groups related to maternal interactions and responsiveness.

Instrument development to study the nature of nurse–patient relationships began in the 1960s, with the most recent instrument published in 2011 (Dearing & Steadman, 2011). The relatively few numbers of instruments may be explained in part by the phenomenological nature of the theory (Haber, 2000) and in part by its complexity. Table 10.3 provides an overview of some of those instruments.

Table 10.3 Instruments Used to Test Theory of Interpersonal Relations

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Peplau has contributed to both the processes used to develop nursing's body of knowledge and the content of that knowledge base. “Optimistically, legitimatization of practice-derived theory in the 1990s will make theory-testing and hypothesis-generating qualitative research related to Peplau's model a priority for nurse researchers in the new millennium” (Haber, 2000, pp. 59, 60). Peplau and others have suggested research needs or questions for this new millennium. Peplau (1964) identified the following questions for nurses in general hospital settings:

1. How do nurses distinguish between a demand and a need of a patient? 2. What is the language behavior during the nurse–patient exchange in

the general hospital?

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3. How do patients develop sufficient flexibility to incorporate body image changes into views of self after major surgery or major life experiences? What nursing interventions are most helpful to patients during this process?

4. How does the one-to-one relationship fit into the present and the future health care delivery system? (pp. 81, 82).

Perhaps the most fundamental and pervasive question that researchers of the nurse–patient relationship can ask and attempt to answer is, What aspects of the nurse–patient relationship contribute to the welfare and well- being of patients? (Caris-Verhallen, Kerkstra, & Bensing, 1997). The promotion of the welfare of patients is core to all nursing theories, but for Peplau, the means of achieving that goal focuses on the attributes and behaviors of both the nurse and the patient and in the dynamic interaction that occurs between them.

Applications of the Theory: Practice Peplau's theory of interpersonal relations has remained popular with nurses, in earlier years particularly those practicing psychiatric–mental health nursing. Surveys of psychiatric nurses in Canada and the United States found over half of them claiming to use Peplau's theory in their practices (Forchuk, 1993, p. 28). Most recently in the field of mental health, the theory has been used to (1) conceptualize the role of mental health consultant liaison (Merritt & Procter, 2010), (2) prepare nurse therapists (Vandermark, 2006), (3) promote therapeutic relationships (Stockman, 2005), (4) care for depressed and potentially suicidal elderly (Campbell, 2001), and (5) prioritize in community mental health settings (Bonner, 2001).

The theory has also been used to consider practice issues of general concern to nurses, for instance, (1) presence (Zblock, 2010), (2) shared decision making (Wills, 2010), (3) quality of life (McCarthy & Aquino- Russell, 2009), (4) altered body image (Wiest, 2006), patient autonomy (Moser, Houtepen, & Widdershoven, 2007), (5) power struggles (Kozub & Kozub, 2004), (6) process of aging (Wadensten & Carlsson, 2003), (7) intentionality (Ugarriza, 2002), (8) stress reduction using reminiscence (Puentes, 2002), and (9) explanation of symptoms (Mahoney & Engebretson, 2000).

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Examples of application to practice in the last 10 years demonstrate how useful the theory is in a broad range of nursing situations. The theory has been used to (1) care for patients in end-stage kidney disease (Graham, 2006), (2) promote computer-mediated communication (Hrabe, 2005), (3) serve as a foundation for assessing needs in a patient with heart failure (Davidson, Cockburn, Daly, & Fisher, 2004), (4) work with younger residents in long-term care setting (Schafer & Middleton, 2001), (5) improve palliative care (Wallace, 2001), and (6) support parents of children with severe meningococcal disease (Haines, 2000). Peplau's theory has also served as a foundation to educate (1) faculty and students on telehealth through distance learning methods (Gallagher-Lepack et al., 2009), (2) patients undergoing urinary diversion to promote their recovery (Marchese, 2006), (3) antepartal patients on prevention of prematurity (Tjedie, 2004), and (4) emigrants on cross-cultural health promotion practices (Kater, 2000). Using Middle Range Theory in Practice 10.2 provides an example of the theory applied to a specific practice issue, and Table 10.4, Examples of Theory in Practice, includes descriptions of several applications, demonstrating the usefulness with different populations and different settings.

Table 10.4 Examples of Theory in Practice

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USING MIDDLE RANGE THEORY IN PRACTICE 10.2

Peplau's theory of interpersonal relations was used to guide the education of patients undergoing urinary diversion. This article outlines each phase with related teaching activities and applies the implementation in case study.

Source: Marchese, K. (2006). Using Peplau's theory of interpersonal relations to guide the education of patients undergoing

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urinary diversion. Urologic Nursing, 26, 363–371. Retrieved from http://www.suna.org/cgi

Problem Prior to surgery, patients can experience anger, grief, fear, and

anxiety related to their diagnosis, testing experiences, and the surgical procedure. Postoperatively, these patients are at risk for multiple complications, for instance, infections, ileus, thrombophlebitis, altered body image, incontinence, and changes in sexual functioning. Needed lifestyle changes occur that require learning about diet and exercise and the management of an altered urinary system. They may also need help addressing their psychosocial needs as they return home and reengage with their communities.

Nursing Intervention The educational strategy was formulated to parallel Peplau's phases

of the interpersonal process. In the orientation phase, the nurse and the patient meet with the goal of the patient accepting the nurse and his/her level of expertise so that the nurse can assess the learning needs of the patient and the patient's readiness to learn. Patients' acceptance of their knowledge deficits serves as motivation to learn. Nurse and patient clarify their expectations for future meetings, establishing mutually agreed upon goals. Nurses engage in (1) assessment of patients' prior knowledge and readiness to learn, (2) determination of mutually determined learning goals, (3) presentation of educational materials, and (4) discussion of surgical options and procedures.

During the identification phase, the focus is on addressing the gaps in the patient's knowledge of the disease, treatment choice, and self-care issues and establishing goals for the preoperative and immediate postoperative periods and for discharge. During this phase, the patient may exhibit independence, overdependence, or isolation/rejection. In this phase, the nurse teaches neobladder care and healthy nutritional practices and works to develop an appropriate activity plan. Successful completion of this stage occurs when the patient recognizes the need for new skills and knowledge to achieve the established goals.

Exploitation is the next stage, characterized by comfort and trust in the relationship between nurse and patient. The patient can identify new learning goals but demonstrates independence and the ability to engage in self-care. In this phase, the nurse reaffirms the patient's

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accomplishments, promotes independence, and helps the patient identify community resources. In the final phase, resolution may take place months after discharge from the hospital. The patient experiences security and a sense of independence and self-reliance. The focus during this phase is on quality of life and integration of a changed health status. The nurse encourages participation in support groups and explores quality of life issues with the patient.

Applications of the Theory: Theory and Model Development Peplau's theory of interpersonal relations is being integrated into new conceptualizations of nursing as a discipline. Using her theory as well as others, Plummer and Molzahn (2009) suggest as a major concept in the metaparadigm quality of life rather than health. Peplau's theory of interpersonal relations has also served as a foundation for the development of other middle range theories and models applicable to practice. Examples include (1) the Model of Simple Reminiscence (Puentes, 2002), (2) Cultural Competence (Warren, 2002), (3) Client–Nurse Interaction Phase of Symptom Management Model (Haworth & Dluhy, 2001), and (4) Interface of Anthropology and Nursing Model (Mahoney & Engebretson, 2000). But Peplau's contributions to nursing are not limited to the content of her theory. She is credited with promoting the “scholarship of nursing practice” (Reed, 1996), integrating nursing practice with a process for ongoing development of nursing's knowledge base.

Summary Peplau is acknowledged as the first theorist of the modern era of nursing. Her theory of interpersonal relations in nursing focuses on the stages experienced, the nursing roles used, and the issues addressed in the context of the nurse–patient relationship. In the nursing profession, the primacy of the nurse–patient

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relationship is still recognized, and Peplau's phenomenological approach to theory development is still valued. “Peplau's work has been influential, particularly (though not exclusively) in mental health nursing and ‘her ideas have provided an architectural design for the practice of a discipline'” (Pearson, 2008, p. 80). Her theory has been used in a variety of practice settings and with many different populations. Peplau was able to pull together “loose, ambiguous data and put them into systematic terms that could be tested, applied, and integrated into the practice of psychiatric nursing” (Lego, 1980, p. 68). Because of its complexity, research on the theory of interpersonal relations is not a simple undertaking, further testing of Peplau's theory could make significant contributions to nursing's body of knowledge.

Critical Thinking Exercises

1. In what ways might Peplau's theory of interpersonal relations need to be revised to be most useful to nurses in a health care environment in which contact time between nurse and client is limited?

2. The surrogate role is not one that is frequently mentioned in recent nursing practice literature. Is that role as defined by Peplau relevant to nursing practice as currently experienced? If so, in what way? If not, why?

3. Peplau's theory focuses on the one-to-one therapeutic relationship between a nurse and a patient. Are the phases of relationships, roles of the nurse, psychobiological experiences encountered in the relationship, and psychological tasks described by Peplau relevant in other nursing contexts, for example, in relationships between nurses? If so, what are some examples of these contexts? If not, why?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Interpersonal Relations.

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http://thePoint.lww.com/Peterson4e

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Boling, A. (2003). The professionalization of psychiatric nursing: From doctors' handmaidens to empowered professionals. Journal of Psychosocial Nursing and Mental Health Services, 41, 26–40. Retrieved from www.jpnonline.com

Butts, J. B., & Rich, K. L. (2015). Philosophies and theories for advanced nursing practice (2nd ed.). Boston, MA: Jones & Bartlett.

Callaway, B. J. (2002). Hildegard Peplau: Psychiatric nurse of the century. New York, NY: Springer.

Caris-Verhallen, W., Kerkstra, A., & Bensing, J. (1997). The role of communication in nursing care for elderly people: A review of the literature. Journal of Advanced Nursing, 25, 915–933.

Courey, T. J., Martsolf, D. S., Draucker, C. B., & Strickland, K. B. (2008). Hildegard Peplau's theory and the health care encounters of survivors of sexual violence. Journal of the American Psychiatric Nurses Association, 14, 136–143. doi: 10.1177/1078390308315613

Davidson, P., Cockburn, J., Daly, J., & Fisher, R. S. (2004). Patient- centered needs assessment: Rational for a psychometric measure for assessing needs in heart failure. Journal of Cardiovascular Nursing, 19(3), 164–171.

Dearing, K. S., & Steadman, S. (2011). The psychometric properties of the self-assessment of the Interpersonal Relationship Scale. Perspectives in Psychiatric Care, 47(4), 176–182. doi: 10.1111/j.1744- 6163.2010.00287.x

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11 Attachment Trine Klette and Sandra J. Peterson

Definition of Key Terms

Attachment An innate psychobiological urge to form lasting bonds with a primary caregiver

Early interaction Dyadic activities performed by a child and its caregiver

Patterns of attachment The distinct ways an individual tends to behave when feeling distressed

Internal working model Basic assumptions about oneself, others, and the interaction with others

Sensitivity The ability to perceive and understand signals from others

Affective empathy An individual's congenital tendency to identify with the emotions of others

Cognitive empathy A developmentally conditioned ability to understand and take the perspective of others

Comfort Activities based on an individual's capacity for sensitivity and empathy whose goal is to relieve distress

Health Composite process and phenomenon including experience of physical well-being, sense of logical coherence, meaningful social functioning, and feeling of security

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Care Watchful and gentle ways of attending to the needs of others

Nursing care Theoretical and training-based knowledge and skills in ways of attending to the basic needs of individuals or groups of individuals, independent of age, sex, ethnic background, or beliefs, with regard to context and the given environments

Historical Background Attachment theory was first presented by John Bowlby in 1957 in the form of three lectures for the British psychoanalytic society. In the first lecture, “The nature of the child's tie to its mother,” Bowlby claimed that the human child is ready to enter into interaction and relations from the moment it is born. By proposing this, he opposed two of the dominant theories on child development at that time: the theory of secondary drive and the theory of object relations (Klette, 2007). Building on Freud's work on the subconscious and transference but opposing his theories of psychosexual phases and aggression as basic developmental forces, Bowlby proposed that it is the real-life interactions and experiences that are most important for an individual's psychological health. The actual satisfaction or denial of basic needs during the upbringing years (not fantasies or phases) is the basis for an individual's capacity to enter into and maintain social relations. The latter is seen as fundamental to psychological health. By claiming this, Bowlby moved attention on human development and functioning from intrapersonal conflicts to interpersonal relations.

Description of Attachment Theory Integrating knowledge from medicine, ethology, learning theories, developmental biology, and psychology, John Bowlby presented the theory on human attachment. Observations of animal behaviors had been of great importance when he stated that all primates are conditioned to

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seek proximity to a caregiver for the purpose of protection and survival (Harlow, 1958). Having an inborn, specific repertoire of communicative expressions and functions, human infants are normally able to exhibit specific behaviors to establish and maintain proximity to caregivers (Simpson & Belsky, 2008). These are smiling and vocalizing (signaling behaviors), crying and screaming (aversive behaviors), and sucking and clinging (active behaviors). During childhood and adolescence, these behaviors mature and integrate and will vary in strength until they are referred to the backseat as Bowlby put it (Bowlby, 1958). But all the attachment-related behaviors are maintained at different levels of activity and will be used in new combinations throughout life. When danger or threats occur, they may be demonstrated just as strongly as in childhood, especially crying and clinging.

Initially, it was the observations of children's responses to separations from their primary caregivers that had caught Bowlby's attention. These observations led among others to the description of three phases of reactions to such separations: protest, grief, and denial. The longer the separations had lasted and the younger the child had been when the separation had occurred, the more serious the psychological disturbances were observed to be (Bowlby, 1960). Attachment theory describes how and why an infant organizes and integrates behavior focused on a specific mother figure during the first year of life. Because the first attachment relationship is of vital importance to the child, separation from the primary caregiver is experienced as utterly threatening. According to the theory, attachment relationships are the products of a behavior response system, which “supervise” the physical presence, and the psychological availability of the mother figure and activates/regulates attachment behavior directed at her (Ainsworth & Bowlby, 1989; George & Solomon, 1996). From a biologic point of view, such behavior enhances the infant's probability of survival and later reproduction. As long as the infant feels safe, the attachment figure functions as a secure base for exploration, play, and other social activities. But when the child feels distressed, the goals of exploration are normally overruled by the need for protection from the caregiver. Between 8 and 18 months, separations from the primary caregiver cause particularly intense distress in a child. Even though the attachment system never locks down, it becomes increasingly invisible over the years (Bowlby, 1958).

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Definition of Key Concepts

Attachment Bowlby described the core of attachment to be a child's preferred wish for contact with its primary caregiver when feelings of threats occur (Bowlby, 1958). The establishment of attachment relationships develops through phases. The first three take place between birth and the age of 3. From 7 months to 3 years of age, the three primary functions of attachment are most noticeable:

1. Proximity maintenance: staying close to and resisting separations from the attachment figure

2. Safe haven behavior: turning to the attachment figure for support and comfort

3. Secure base behavior: using the attachment figure as a base for exploration and other nonattachment activities

The fourth phase, which begins about 3 years of age, normally implies a child's increased ability to take the caregiver's perspective and develop a “goal-corrected partnership” with the caregiver (Posada et al., 1995; Simpson & Belsky, 2008).

Internal Working Models On the basis of the child's needs and demands and the caregiver's responses, basic beliefs, expectations, and attitudes about relationships develop. Such mental representations were termed internal working models by Bowlby (1988). The development and integration of the internal working model includes and affects the psychological, physiological, social development, and functioning of the child (Hofer, 1994; Luecken, 2000; Roisman et al., 2009; Schore, 1994). The core in a child's working model of the world is the comprehension of who the attachment figure is, where it can be found, and how it can be expected to respond when called upon. The perception of how acceptable the child is in the eyes of the

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caregiver is seen as the core in the child's inner working model of the self. A child growing up with available, predictable, and supportive parents tends to construct an internal working model of itself as capable and worthy of help and support. Children experiencing little or unpredictable response and support or have caregivers who threaten, harm, or abandon them tend to develop internal working models of themselves as unworthy, unloved, or ineffective. Some of these children might, however, develop positive internal working models of their caregivers to be able to live in and tolerate the relationship. Regardless of the upbringing, as an internal working model matures and integrates, it becomes gradually subconscious and automatic.

Patterns of Attachment Bowlby's collaboration with psychologist Mary Ainsworth represented a breakthrough with regard to further research and application of attachment theory. Based on a study of attachment-related behavior among families with small children in Baltimore, Ainsworth was able to describe certain distinct patterns of attachment behavior (Ainsworth, Blehar, Waters, & Wall, 1978). These patterns were, respectively, termed secure, anxious avoidant, and anxious ambivalent (see below). Ainsworth also constructed the classic observational method for studying attachment behavior in children between 8 and 18 months: “The Strange Situation Procedure” (Ainsworth & Bell, 1970). The procedure, lasting for about 20 minutes, consists of seven episodes including two short separations between the child and the caregiver. In the first separation episode, the child is left with a stranger, and in the second, it is left alone. Since the attachment system is open and visible at this age, trained coders will be able to ascribe the children to either of the following categories:

Secure attachment: A securely attached child is generally described as emotionally open and straightforward, claiming comfort and protection from the caregiver when distressed and able to settle down and eventually exhibit creative playfulness when they feel secure. The secure pattern is associated with available, predictable, and sensitive caregiving (see below). Ainsworth described four subpatterns of the secure pattern.

Anxious avoidance: A child who has developed an anxious–avoidant pattern of attachment generally tries to suppress or hide open

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manifestations of negative emotions and reactions when distressed, avoiding eye contact with the caregiver and often using toys as a distraction. This pattern is associated with relatively consistent distant, reserved, rejecting, or punitive caregiving. Maltreated children with this pattern are most likely to have been victims of physical and emotional abuse (Weinfeld, Sroufe, Egeland, & Carlson, 2008). Ainsworth described two subpatterns of anxious avoidance.

Anxious ambivalence: Children who develop an anxious ambivalent pattern of attachment show mixed emotions toward their caregiver when distressed. Conspicuous helplessness and passivity alternate with outbursts of aggression or fear. A child with an anxious ambivalent pattern of attachment tends not to explore the surroundings very much but concentrates its attention on the caregiver's whereabouts. The pattern of anxious ambivalence is associated with unpredictable caregiving, where the caregiver tends to follow his/her own impulses rather than consistently responding to the signals and needs of the child. Maltreated children displaying this pattern of attachment are most likely to have been victims of neglect (Weinfeld et al., 2008). Ainsworth described two subpatterns of anxious ambivalence.

Disorganized attachment: By describing the pattern of attachment and developing a procedure for observing attachment behavior in small children, attachment research developed rapidly (Cassidy & Shaver, 2008). It soon became clear, however, that some children could not be ascribed to any of the original patterns described by Ainsworth. These children, who exhibited a confusing mixture of behavioral responses, often combined with tics and other bodily oddities were eventually described as disorganized with regard to attachment (Main & Hesse, 1990; Main & Solomon, 1990). Disorganized attachment is particularly associated with fearful and/or frightening parenting that makes it impossible for the child to develop a coherent attachment pattern. Prolonged isolation, neurological problems, and pharmacologic interventions have later been added to the precursors for disorganized attachment. It has been speculated that the seemingly meaningless body movements seen in many children with disorganized attachment correspond to what is described as conflict behavior in animals. That is, the movements are expressions of the impossible in the child's situation, caught as it is between the drive and the need to seek closeness to and protection from the caregiver and the impulse to fight or flee from the very same person.

Earned secure: Adults have been observed who, despite strong

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evidence of unloving parents and a harsh upbringing, appear coherent and balanced with regard to attachment in the Adult Attachment Interview. These individuals were described as “earned secure” (Hesse, 2008; Pearson, Cohn, Cowan, & Cowan, 1994). Studies indicate that attachment- related behavior is as stable and robust with earned security as with natural security. Alternative secure attachment and psychological treatment seem to account for such positive changes of an attachment strategy. 1The Adult Attachment Interview is a semistructured interview about attachment-related episodes from the childhood to the present (George, Kaplan, & Main, 1985).

Attachment as a Basic Need By describing the basic human needs, Abraham Maslow (1970) made a great contribution to the works of a variety of disciplines, including nursing. Although the need for attachment is not explicitly addressed in Maslow's pyramid, it is touched upon through (the needs for) shelter, protection, security, family, relationships, and so on. It is, however, strongly indicated by research that the need for attachment not only is a need in its own right but also in fact is a central one. With great respect to Maslow's invaluable work, a pyramid that is modified to integrate attachment needs is suggested in Figure 11.1.

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Figure 11.1 Maslow's pyramid modified to integrate attachment needs.

Attachment and Care Attachment theory gives strong evidence to the importance of meeting a child's need for contact and closeness with understanding, respect, and warmth. It also gives evidence on the importance of care in general and in cases of disease, illness, and loss in particular. Individual care factors known to promote attachment security are availability, predictability, and sensitivity. Socially contributing factors are extended networks, education, stable incomes, preventive health care, and a general social stability (Cassidy & Shaver, 2008; Killén, Klette, & Arenevik, 2006; Solomon & George, 1996).

Individuals who have received adequate care during childhood tend to be open and trusting toward others and also exhibit empathy and caring behavior toward needs of others. Individuals who have experienced rejection, abuse, and little comfort and protection during childhood tend to withdraw, trivialize, or dismiss care needs. Individuals who have been exposed to unpredictable and neglectful care seem to alternate between passivity and intrusive behavior (Klette, 2007).

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Attachment relationships will be formed throughout life and when first formed, such relationships tend to be strong and important, for better or worse. Attachment theory offers an opportunity to understand, observe, and change some apparently fixed premises for human behavior. Instead of assigning behaviors merely to genetic conditions and individual dispositions, attachment theory and research have shown that crucial social behavior is learned through interaction and care (see Fig. 11.2).

Figure 11.2 Factors underlying the patterns of attachment.

Attachment and Health Health is understood as a process and phenomenon that includes experience of physical well-being, sense of logical coherence, meaningful social functioning, and the feeling of security. Seen in this light, secure attachment accounts for many positive health-related conditions and functions. Among other things, a marked lack of securely attached individuals is found in various clinical psychiatric samples (van IJzendoorn, Goldberg, Koonenberg, & Frenkel, 1992). As mentioned

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earlier, basic beliefs/expectations/attitudes and patterns of self-protective behavior tend to re-emerge in times of threats, illness, or loss (Bretherton & Munholland, 2008). Bowlby described the early behaviors (crying, clinging, etc.) as old soldiers who are put to rest, but who will rise again when needed. How and to which extent the old soldiers will fight will vary according to the attachment strategy of the individual. Signs of secure attachment are, among other things, trust and ability to ask for and make use of help and care. Securely attached individuals also tend to be more balanced and flexible than individuals with other attachment experiences, and they are better able to regulate and adjust their feelings and reactions to a stressful situation. Evidence of connections between child abuse and neglect, various diseases, and anxious and disorganized attachment is significant (Klette, 2008). A pioneering study by McWilliams and Bailey (2010) shows strong association between adult attachment ratings and a number of health conditions. The study findings support that insecure (i.e., anxious) attachment is a risk factor for disease and chronic illness, particularly conditions involving the cardiovascular system. See also Donovan and Leavitt (1985), Reite and Field (1985), Spangler, Schieche, Ilg, Maier, and Ackerman (1994), and Hofer (2003) for studies of associations between attachment and psychobiology.

Epigenetics is a new research area that offers significant insights into the interaction between genes and environment. Among others, studies show that the quality of care received in early age inflicts upon the development of the brain and behaviors by altering processes that control the expression of the DNA. Enzymes that block, repair, and switch functions of the genes on and off are described. The findings indicate that psychiatric diseases are related to stress in relation to primary caregivers or significant others in childhood (Donovan and Leavitt (1985); Fosse, 2009; Heim, Newport, Bonsall, Miller, & Nemeroff, 2003; Luecken, 2000; Szyf, McGowan, & Meaney, 2008).

Development and Change If the upbringing conditions of a child remain unaltered, the basic attitudes, expectations, and behavioral strategies also tend to remain unchanged. If the conditions change for the better, the internal working model and the pattern of attachment may change in a more secure direction. If the conditions change for the worse, they may change in an

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anxious or even disorganized direction. Earned security (see above) indicates that attachment status can be altered throughout life, but it appears to become increasingly resistant to change. The problem with changing status of attachment is probably not least due to the subconscious and automatic character of the internal working model. But also the common tendency to believe that an attachment pattern is the product of individual dispositions probably accounts for this. The first years and the puberty period seem to be most susceptible to attachment-related influence and change, but the attachment system also tends to open up for adaptation during pregnancy and in the postpartum period as well as in cases of loss, illness, or disease. According to Bowlby, the ability to change is reduced with age, but changes occur throughout life, which means that an individual is always open to positive influence.

Applications of Attachment Theory: Research Attachment theory research highlights the importance of preventive health care directed at families with small children. Guidance, practical help, and emotional support with regard to behaviors that facilitates secure attachments appear to be among the best ways to promote health and prevent disease. Obtaining knowledge about attachment may help many parents to improve their interactive behaviors. Others will need much supervision and close follow-up to be able to change destructive patterns. Some parents, independent of the investments made, will still not be able to change, and therefore, alternative care should be found. Virginia Henderson's concepts of strength, will, and knowledge may prove very useful in assessing and addressing attachment-related health behaviors. They can be seen as corresponding to the phenomena of the internal working model: expectations, attitudes, and assumptions.

Although it is known to be of great importance for health care behaviors, the phenomenon of will is still quite elusive and unclear. Henderson equaled will to “love of life,” and psychologist Rollo May (1969) describes will not as an independent ability or special personality trait, but as a product of care. Will and wish cannot be the basis of care, but rather the opposite, they are found on and manifest themselves as

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liberated and activated care. By describing the internal working model and the patterns of attachment, Bowlby and Ainsworth provided new insights into the phenomenon of will. Some patients apparently do not, despite huge investments, want to change their self-destructive behaviors or engage in health-preventive activities. Taking the patient's attachment experiences into account may prove valuable when planning interventions. A definition of will as the ability to be or do something, rooted in attachment experiences, is suggested.

Much of the current research is published either in nonnursing journals or by international nurses. Published research demonstrates the applicability of attachment theory across cultures and to populations throughout the life span. Sen and Kavlak (2012) provide an example of research focusing on attachment across generations. Research has been conducted to consider the attachment issues of premature infants (Tilokskulchai, Phatthanasiriwethin, Vichitsukon, & Seriathien, 2002), infants with low birth weights (Wolke, Eryigit-Madzwamuse, & Gutbrod, 2014; Gathwala, Singh, & Balhara, 2008), infants with orofacial clefts (Habersaat et al., 2013), and infants from low-income Korean families (Lee, McCreary, Breitmayer, Kim, & Yang, 2013).

There has also been an interest in research of attachment among the elderly. For instance, (a) Cicirelli (2010) concluded that attachment networks were important for maximum adaptation in old age; (b) Verdecias, Jean-Louis, Zizi, Casimir, and Browne (2009) found in the elderly possible associations between secure attachment styles and positive but subjective measures of sleep; (c) Gillath, Johnson, Selcuk, and Teel (2011) demonstrated a relationship between securely attached older adults and the maintenance of social ties with subsequent low levels of depression; and (d) Loetz et al. (2013) found that in palliative care situations, there is a dialectical balance between security and separation, phenomena common in both attachment and spirituality.

A number of measurements and programs for intervention have been developed since Ainsworth's strange situation, and great advances have been made in measuring attachment throughout the life span. The Q-set methods have been used to assess attachment in preschool-aged children (Waters & Deane, 1985). The research described in Using Middle Range Theory in Research 11.1 provides an example of an instrument used in the study of attachment.

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USING MIDDLE RANGE THEORY IN RESEARCH 11.1

Source: Killén, K., Klette, T., & Arenevik, E. (2006). Tidlig mor-barn samspill i norske familier (Early mother–child interaction in Norwegian families). Tidskift for Norsk Psykologforening, 43, 694–701.

Purpose/Research Question The aim of the study was to investigate relations between early

mother–child interaction and the development of attachment.

Research Design Prospective longitudinal design.

Participants There were 293 mother–child dyads, observed from 3 months until

4½ years old. The participants were from different socioeconomic districts in Norway and also included dyads from mother–child institutions.

Data Collection The procedures used in the study were the Care Index (see below),

Ainsworth's strange situation, and a short questionnaire concerning education, income, social network support, drug abuse, and medical diagnoses.

Care Index The Care Index is a scoring system for observing parent–child interaction under nonthreatening conditions on the basis of short videotapes (Crittenden, 2000). Sensitivity to the child's signals is the central concept that the Care Index coding system is built around. Crittenden defines adult sensitivity as a behavior pattern that pleases the child most, increases its well-being, and reduces its distress, and it is seen as a dyadic concept. According to the definition, it also incorporates the child's temperament and mother's empathy. The mothers' behavior is scored by a two-point scoring system on the three

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dimensions: sensitive, passive, or controlling (open or hidden). The child's behavior is scored on four dimensions: cooperative, difficult, passive, or compulsive compliant. The behaviors scored include seven elements: (1) facial expression, (2) vocal expression, (3) position and body contact, (4) expression of affection, (5) turn-taking contingent, (6) control, and (7) choice of activity. The first four of these aspects are assessment of affect within the dyad. The final three refer to temporal contingencies. The two points could both be placed on one dimension (for instance, sensitive), or they might be split (for instance, between sensitive and controlling). The sum of the score should always be 14 points. Obtaining between 11 and 14 points on the sensitive and cooperative scales can, according to Crittenden, be considered sufficient for the “sensitive” and “cooperative” categories. Scores between 7 and 10 points are classified as “adequate (for adults) and mixed cooperative (for infants).” Less than six sensitive or cooperative items should yield classifications of “inept” (5 to 6) and “at risk” (0 to 4), which can be “controlling” and/or “unresponsive” (for adults) and “difficult” and/or “passive” (for infants). The Care Index is considered useful in applied settings to screen for risk, guide intervention, and assess some outcomes of treatment. When used diagnostically, it is emphasized that the data provided by the Care Index would constitute only one part of information, which could be useful in conjunction with other information.

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Results From the Care Index, strong correlations were found between

education, social network, social stress factors, and the mothers' sensitivity at the first two observations. At 6 to 7 months, but not at 3 to 4 months, there were observed significant differences in sensitivity between mothers exposed to, respectively, low and high socioeconomic stress. At both points of observation, significantly lower sensitivity was seen in the mothers from the mother–child institutions. The Care Index categories were, however, found to be too detailed for clinical use. It was, therefore, suggested that they should be divided into three: “good enough” interactions (more than eight points), “at-risk” interactions (7 to 5 points), and “maltreatment” interactions (4 to 0 points).

The main finding was that the use of the three classification categories could predict infant attachment at one year and therefore might be used to serve as a basis for selective and indicated prevention as well as early intervention.

A number of instruments have been developed to assess attachment in adults. The Attachment Script Assessment (ASA) is a narrative measure using a set of prompt words to create a story about an attachment issue (Waters & Rodrigues-Doolabh, 2004). The more common approaches include the Adult Attachment Interview (AAI) that assesses general and specific memories of childhood (Hesse, 2008) and the Adult Attachment Projective Picture System (AAP), which involves telling stories based on picture stimuli (George & West, 2012).

Applications of Theory: Practice As with applications of attachment theory to research, the theory can be used in practice throughout the life span. This use begins with the newborn population and proves useful until the later years of life. For instance, to promote parental attachment with newborns, nurses can foster nurturing touch by allowing parents as much access to their new child during the first hour of his/her life and throughout their time in the hospital. Breastfeeding provides prolonged times of contact between mother and

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child. The U.S. Baby-Friendly Hospital Initiative, 2010, has stated guidelines and evaluation criteria that support breastfeeding, and nurses can encourage its adoption. Nurses can also encourage parents to get to know their infant using the sense of touch (Duhn, 2010; Karl, Beal, O'Hare & Rissmiller, 2006). See Table 11.1 for expanded descriptions of Duhn's and Karl et al.'s recommendations and other specific examples of the theory used in practice.

Table 11.1 Examples of Attachment Theory for Practice

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The Circle of Security is a relationship-based early intervention program designed to enhance attachment security between parents and children. Decades of university-based research have confirmed that secure children exhibit increased empathy, greater self-esteem, better relationships with

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parents and peers, enhanced school readiness, and an increased capacity to handle emotions more effectively when compared with children who are not secure.

Attachment theory has been most frequently applied to work with children. The federal program in the United States, Early Head Start, is a visible example of a practice application of this theory (Boris & Zeanah, 2011). The Circle of Security Project is a relationship-based intervention program based on attachment theory that is designed to help parents and even therapists help children become more secure in their relationships. Security is associated with increased empathy, school readiness, and the ability to manage emotions more effectively (http://circleofsecurity.net/).

The theory has also been used with children who have been mistreated (Allen, 2011) and children with disabilities (Howe, 2006; Wilkins, 2010). It has been found useful in situations where child custody was an issue (Garber, 2009; Marvin & Schutz, 2009), as well with children being adopted or in foster care (Walker, 2008) or placed in residential homes (News, 2014). Using Middle Range Theories in Practice 11.2 discusses the use of the theory by health care workers involved in adoption or foster care evaluations.

USING MIDDLE RANGE THEORIES IN PRACTICE 11.2

Problem The selection of substitute caregivers and matching a child with a

caregiver for children who are being adopted or placed in foster care is an important and challenging decision. Healthy adjustment is dependent on an appropriate placement.

Intervention Attachment theory provides a framework for assessing the qualities

of potential caregivers and children. Assessment of the caregiver should include (a) the ability to manage a wide range of feelings of self and others, (b) the resolution of past personal losses or traumas, and (c) the ability to engage in reflection. The assessment of the child is also a critical consideration in placement decisions. A trained health

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http://circleofsecurity.net/

professional can assess a child's attachment pattern during times of distress or fear. Of particular concern in placement is manifestation of disorganized attachment, in which children view caregivers as a source of danger and therefore must be controlled in some fashion. The involved adults' attachment pattern is also important and needs to be assessed, as does the dynamics of the couple relationship. A complementary attachment pattern in couples is considered most resilient. With these assessment data, decisions about appropriate placement of children can be more informed and hopefully result in a growth-producing environment for children.

The use of attachment theory is not limited to involvement with children. It has been found useful by counselors and psychotherapists working with individuals with personality disorders (Fogany & Bateman, 2007; Van den Berg & Oei, 2009), depressed adolescents (Bowlby, 1979; Shaw, Dallos, & Shoebridge, 2009), and those suffering from addiction (Flores, 2006). The theory has also been applied to involvement with adult cancer patients and their partners (Burwell, Brucker, & Shields, 2006) and more recently as it relates to spiritual coping in older adults (Munnichs, Bowlby, & Miesen, 1986; Pickard & Nelson-Becker, 2011). There is also a growing interest in the use of attachment theory in nursing education, particularly as it relates to the mentor/mentee relationship (Miles, 2011). Table 11.1 provides additional examples of the theory's applications to practice.

Further Research There is a vast area of attachment research challenges and possibilities relevant to nursing. There are, for instance, strong warrants for further research regarding the role of attachment in the development of specific health conditions (McWilliams & Bailey, 2010). The study of attachment and comfort (Klette, 2007) also calls for further investigations. Other areas of importance are transgenerational continuities and discontinuities of attachment and the development of the earned secure status. Even though continuity seems to be a rule, there is much evidence of variety and change regarding the internal working models and patterns of attachment in adult attachment relationships. According to Bowlby, it is the quality of interpersonal communication that is the major factor in deciding whether a

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child or adult is in a secure, anxious, or distressed state (Kobac & Madsen, 2008). Further development of reliable measurements and programs for clinical intervention is also called for, especially with regard to school-age children and the very old.

Summary John Bowlby used knowledge from multiple disciplines to explain children's reactions to separations from their primary caregivers and develop attachment theory. According to Bowlby, attachment theory is a theory about human development and the needs of people from the cradle to the grave. A number of disciplines have included the theory of attachment in their body of knowledge and have contributed to its development as a theory (Cassidy & Shaver, 2008) with the discipline of nursing beginning to become more interested in research related to the theory and to make use of the theory in practice. From a nursing point of view, there are many reasons for this increased interest, for instance, the theory can contribute to the clarification of many concepts/phenomena central to nursing, such as empathy, comfort, care, and health. By taking a patient's attachment experiences and status into account, the nurse will be able to improve the understanding of individual possibilities and limitations, in particular with regard to the phenomenon of will. Reflecting upon own attachment history with regard to attitudes, expectations, and patterns of self-protective behavior might also help nurses be more conscientious in their work. Attachment theory highlights the importance of prevention, a traditionally central field of nursing. The importance of preventing child abuse and neglect cannot be overestimated. While attachment theory and research are yielding an increasing amount of knowledge about the development of health and disease in humans, it is strongly recommended that the discipline of nursing start making more use of and contributing to this multidisciplinary and cross-cultural effort to improve human conditions.

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Critical Thinking Exercises

1. One of the patterns of attachment is referred to as “earned secure.” This pattern, characterized by coherence and balance, is achieved by adults who experienced unloving or harsh parenting. What individual characteristics or life experiences might contribute to achievement of this pattern?

2. Based on this theory, what behaviors would a nurse attempt to engender when working with parents to promote healthy attachment?

3. At times of threat, illness, or loss, self-protective behaviors in adults can emerge. How would adults manifest self-protective behaviors?

4. What is a research question that would provide validation of this theory?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Attachment.

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Allen, B. (2011). The use and abuse of attachment theory in clinical practice with maltreated children, Part II: Treatment. Trauma, Violence & Abuse, 12(1), 3–12.

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Burwell, S. R., Brucker, P. S., & Shields, C. G. (2006). Attachment behaviors and proximity-seeking in cancer patients and their partners. Journal of Couple & Relationship Therapy, 5(3), 1–16.

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Flores, P. J. (2006). Conflict and repair in addiction treatment: An attachment disorder perspective. Journal of Groups in Addiction and Recovery, 1(1), 5–26.

Fogany, P., & Bateman, A. W. (2007). Mentalizing and borderline personality disorder. Journal of Mental Health, 16(1), 83–101.

Fosse, R. (2009). Ingen gener for psykiske lidelser (No genes for psychiatric diseases). Tidsskrift for Norsk Psykologforening, 46(6), 596–600.

Garber, B. D. (2009). Attachment methodology in custody evaluation: Four hurdles standing between developmental theory and forensic application. Journal of Child Custody, 6(1–2), 38–61.

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George, C., Kaplan, N., & Main, M. (1985). Adult attachment interview. Unpublished manuscript. Department of Psychology, Berkeley, CA: University of California.

Gillath, O., Johnson, D. K., Selcuk, E., & Teel, C. (2011). Comparing old and young adults as they cope with life transitions: The links between social network management skills and attachment style to depression. Clinical Gerontologist, 34(3), 251–265. doi: 10.1080/07317115.2011.55434

Habersaat, S., Monnier, M., Peter, C., Bolomey, L., Despars, J., Pierrhembert, B., …, Hohlfeld, J. (2013). Early mother-child interaction and later quality of attachment in infants with orofacial cleft compared to infants without cleft. Cleft Palate-Craniofacial Journal, 59(6), 704–712. doi: 10.1597/12-094.1.

Harlow, H. (1958). The nature of love. In J. M. Notterman (Ed.), The evolution of psychology; Fifty years of the American psychologist (pp. 41–64). Washington, DC: American Psychological Association.

Heim, C., Newport, D. J., Bonsall, R., Miller, A. H., & Nemeroff, C. B. (2003). Altered pituitary-adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. American Journal of Psychiatry, 158, 575–581.

Hesse, E. (2008). The adult attachment interview: Protocol, methods of analysis, and empirical studies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Attachment theory, research and clinical applications (2nd ed., pp. 552–599). New York, NY: Guilford Press.

Hofer, M. A. (1994). Hidden regulators in attachment, separation, and loss. Monographs of the Society for Research in Child Development, 59, 192–207.

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Howe, D. (2006). Disabled children, parent–child interaction and attachment. Child and Family Social Work, 11(2), 95–106.

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Lee, G., McCreary, L., Breitmayer, B., Kim, M. J., & Yang, S. (2013). Promoting mother-infant interaction and infant mental health in low- income Korean families: Attachment-based cognitive behavioral approach. Journal for Specialists in Pediatric Nursing, 18(4), 265–276. doi: 10.1111/jspn.12034

Loetz, C., Műller, J., Frick, E., Petersen, Y., Hvidt, N. C., & Mauer, C. (2013). Attachment theory and spirituality: Two threads converging in palliative care? Evidence-based Complementary and Alternative Medicine, 2013, 1–14. doi: 10.1155/2013/740291

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Miles, K. (2011). Using attachment theory in mentoring. Nursing Times, 10(380), 23–25.

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PART V Middle Range Theories: Integrative

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12 Modeling and Role-Modeling

Ellen D. Schultz

Definition of Key Terms

Adaptation Adaptation is the “process by which an individual responds to external and internal stressors in a health and growth- directed manner” (Erickson, Tomlin, & Swain, 1983, p. 252).

Affiliated individuation Affiliated individuation is an inherent need to be dependent on support systems while maintaining a sense of autonomy and separateness from those systems.

Environment The client's environment includes internal and external stressors as well as internal and external resources (Erickson, 1989). The theorists see environment in the “social subsystems as the interaction between self and other both cultural and individual” (Erickson, 2002a, p. 452).

Facilitation Through the interactive process of facilitation, the nurse assists the client to “identify, mobilize, and develop” personal strengths. The nurse does not affect the outcomes for the client but rather helps in the process of moving toward holistic health.

Health Health is a state of equilibrium among the subsystems of the holistic person. It is defined not by the absence of disease but rather by the client's perception of mental, physical, and social well-

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being.

Holism “The interaction of the multiple subsystems and the inherent bases creates holism. Holism implies that the whole is greater than the sum of the parts” (Erickson et al., 1983, p. 45). There is a blending of conscious and unconscious.

Inherent endowment Inherent endowment includes both the genetic makeup of the person and the inherent characteristics resulting from disease and/or birth that may influence the person's health status.

Lifetime growth and development Persons change throughout the lifetime, responding to an inherent desire to fulfill their potential in the areas of basic needs and psychological and cognitive stages.

Modeling Modeling is “the process the nurse uses as she develops an image and understanding of the client's world—an image and understanding developed within the client's framework and from the client's perspective” (Erickson et al., 1983, p. 95).

Nursing “Nursing is the holistic helping of persons with their self-care activities in relation to their health. This is an interactive, interpersonal process that nurtures strengths to enable development, release, and channeling of resources for coping with one's circumstances and environment. The goal is to achieve a state of the perceived optimum health and contentment” (Erickson et al., 1983, p. 49). This requires that the nurse unconditionally accepts the client.

Nurturance “Nurturance fuses and integrates cognitive, physiological and affective processes with the aim of assisting a client to move toward holistic health” (Erickson et al., 1983, p. 48). In order to nurture, the nurse must understand the client's model of the world.

Person “Human beings are holistic persons who have multiple interacting subsystems” (Erickson et al., 1983, p. 44). These dynamic subsystems are the biophysical, cognitive, psychological, and social subsystems. Intersecting and permeating these subsystems are the genetic base and spiritual drive.

Role-modeling In role-modeling, the nurse uses purposeful interventions, based on nursing science, that are unique to the client,

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to assist the client toward holistic health.

Self-care knowledge Self-care knowledge is one's personal understanding of what interferes with or what promotes his or her own health and development.

Self-care resources Self-care resources are internal and external resources that serve as a foundation for growth and can be mobilized to promote holistic health.

Self-care action Clients demonstrate self-care action when they develop and use self-care knowledge and self-care resources. “Through self-care action the individual mobilizes internal resources and acquires additional resources that will help the individual gain, maintain and promote optimal level of holistic health” (Erickson et al., 1983, p. 48).

Stressor A stressor is a stimulus experienced by the individual as a challenge that mounts an adaptive response.

Unconditional acceptance The individual is accepted as a unique and worthwhile human being.

Introduction Modeling and Role-Modeling (MRM) is a theory and paradigm for nursing and serves as a foundation for nursing research, education, and practice. It is among the theories “most commonly used by holistic nurses” (Frisch, 2009, p. 116). As a theory that is strongly tied to nursing practice, it is a positive response to the criticism cited by Fawcett (1995) that many models and theories are “invented by scholars and academics” and therefore may have little relevance for nursing practice (p. 519).

Chapter 1 describes the hierarchy of nursing knowledge and the classification of nursing theories as grand, middle range, or practice theories. While MRM is included here among the middle range theories, consensus has not been established on this classification. Tomey and Alligood (1998) originally classified MRM as a middle range theory but later stated that MRM theory could serve as a guide for nursing practice

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due to its specificity, yet it is abstract enough that middle range theories could be derived from it (Tomey & Alligood, 2002). McEwin and Wills (2002) consider MRM to be a grand theory and categorized it as one of the interactive process theories, while Parker and Smith (2010) list MRM in the category of grand theory in the interactive/integrative paradigm.

One system for classifying theory is to consider the scope of the theory. A grand theory includes the nursing metaparadigm concepts of nursing, health, environment, and person, all of which are addressed in MRM. This chapter is appropriately included in this text because it presents, as components of the grand theory, a number of middle range concepts that have developed from MRM theory. These concepts are best understood within the context of the grand theory.

MRM is a client-centered nursing theory that places the client's perceptions, or model of the world, at the center of the nurse–client interaction. The theory integrates concepts from several interdisciplinary theories including psychosocial development (Erikson, 1968), cognitive development (Piaget, 1952), basic human needs (Maslow, 1968), and stress adaptation (Engel, 1962; Selye, 1976). The expanded description of the theory included energy-based concepts (Brekke & Schultz, 2006). These concepts are linked to those unique to MRM theory. Through the processes of MRM, the nurse facilitates and nurtures the client to achieve high-level, holistic wellness.

Historical Background MRM is a theory “born in practice,” as described by Dickoff, James, and Weidenback (1968). “… Using nursing practice as a basis for theory development promotes not only a broader view of reality but also an increased relevance of theory to practice” (McClosky & Grace, 1994, p. 78). Through observations made in clinical practice in a variety of nursing settings, Helen Erickson became consciously aware of the nurse's role as a healer. Based on a combination of insights gleaned through personal experience, clinical practice, and discussions with her father-in-law, renowned psychotherapist, Milton Erickson, Helen Erickson began, in the mid-1970s, to formulate the ideals that later became MRM theory (Keegan & Dossey, 1998). As a graduate student, Erickson began testing components of the theory, beginning with research on the Adaptive

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Potential Assessment Model (APAM) (Erickson, 2002b; Erickson & Swain, 1982), followed by additional testing of this concept (Barnfather, Swain, & Erickson, 1989a) and the concept of self-care resources (Erickson & Swain, 1990).

The process of articulating and researching MRM concepts and the effects of MRM interventions led the way to the publication of Modeling and Role-Modeling: A Theory and Paradigm for Nursing (Erickson, Tomlin, & Swain, 1983). This text made the theory more accessible to nurses, thus promoting the use of MRM in practice, education, and research. The publication of Modeling and Role-Modeling: A View from the Client's World (Erickson, 2006) offered a deeper understanding of the basic concepts of the theory, an articulation of beliefs that were implied but not specifically described in the first text on MRM theory, as well as additional ways to apply the theory in practice. Erickson discusses beliefs that are central to her model of the world. She thoughtfully articulates her reason for being in this way. “Reflection … has led me to conclude that my Life Purpose is to nurture growth in others.… Looking back at my life … attaching meaning to significant experiences and memories, I've concluded that nurturing growth is tantamount to facilitating self- actualization of finding-of-Self in others.… I am satisfied that this is my Life Purpose” (p. 28).

The link between knowledge and practice, the basis for Erikson's work, continues to be articulated in Exploring the Interface Between the Philosophy and Discipline and Holistic Nursing: Modeling and Role- Modeling at Work (Erickson, 2010a). This text is a rich blend of the philosophy of MRM and holistic nursing with the practical application of the theory in both nursing education and practice.

Expanded Definitions of Modeling and Role-Modeling Concepts MRM theory is described in terms of its theoretical bases, including how people are alike and how they are different, a philosophy of nursing and a paradigm for the practice of nursing. For the purpose of defining the major concepts of the theory, they can be categorized into concepts that relate to nursing and those that relate to persons. The concepts are defined

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individually, but in practice, several concepts may work together to operationalize the theory.

Concepts Related to Nursing Erickson has identified and described several concepts that related to the discipline of nursing. They include nursing, facilitation, nurturance, unconditional acceptance, modeling, and role-modeling.

Modeling Modeling is a central concept in the theory because understanding the client's viewpoint is the foundation for implementing the nursing process. Modeling is defined as “the process the nurse uses as she develops an image and understanding of the client's world—an image and understanding developed within the client's framework and from the client's perspective” (Erickson et al., 1983, p. 95). Modeling begins with the initiation of the relationship with the client as the nurse seeks to determine the person's worldview. Modeling is a central concept because “this worldview helps us to understand what that person perceives to be important, what has caused his problems, what will help him, and how he wants to relate to others” (Erickson, 2010a, p. 205).

Both the art and the science of nursing are reflected in modeling. The art is demonstrated through the use of therapeutic communication to develop an accurate picture of the client's situation. The science is demonstrated in the data aggregation and analysis based on scientific principles and the concepts from the theory.

Role-Modeling “Role-modeling is the facilitation of the individual in attaining, maintaining, or promoting health through purposeful interventions” (Erickson et al., 1983, p. 95). Role-modeling can occur only after the nurse accurately understands the client's worldview. The art of role-modeling is demonstrated by planning and implementing nursing interventions that are based on the client's model of the world and are, therefore, unique. The science of role-modeling is demonstrated through planning theory-based

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interventions. Data are analyzed using the theory propositions and linkages, discussed elsewhere in this chapter.

Nursing MRM emphasizes the holistic, interpersonal nature of nursing. Nursing is described as an interactive process that nurtures client strengths to “enable development, release and channeling of resources for coping with one's circumstances and environment. The goal is to achieve a state of perceived optimal health and contentment” (Erickson et al., 1983, p. 49). In the process of assisting clients to achieve holistic health, the nurse must nurture the client; facilitate, not effect, the process; and accept the client unconditionally.

Facilitation Through the interactive process of facilitation, the nurse assists the client to identify, mobilize, and develop personal strengths as he or she moves toward health. The nurse does not produce the outcomes for the client but rather “aids the client in meeting his or her own needs so that he or she may have the necessary resources” for coping with stressors, growth, development, and self-actualization (Erickson, 1990, p. 13).

Nurturance In the process of nurturance, the nurse promotes the integration of the client's affective, cognitive, and physiologic processes as the client moves toward holistic health. For nurturance to occur, the nurse must seek to understand and support the client's model of the world and appreciate the value of the client's self-care knowledge. This understanding can be used to develop nursing interventions that are unique to the client.

Unconditional acceptance The nurse accepts the client as a “unique, worthwhile, important individual with no strings attached” (Erickson et al., 1983, p. 255). Empathy is used to communicate nonjudgmental respect with the client. The experience of

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receiving unconditional acceptance leads to sense of dignity and worth and “trust in the provider” (Erickson, 2006, p. 342).

Concepts That Relate to Persons In describing the concepts that relate to person, Erickson has included concepts formulated for the theory and others that rely on borrowed theories from other disciplines. While nursing seeks to develop “distinctive knowledge” related to the discipline of nursing, the linking of borrowed theory with nursing theory is appropriate if there is congruence between the worldviews of the two (Villarruel, Bishop, Simpson, Jemmott, & Fawcett, 2001). Concepts that relate to persons that have been described in MRM theory include person, health, environment, ways the people are alike, and ways in which they differ.

Person The individual is viewed as holistic, having multiple interacting subsystems. These dynamic subsystems are the biological, cognitive, psychological, and social subsystems. The person's genetic makeup and spiritual drive permeate and intersect the subsystems. When caring for the person, the nurse does not focus on one subsystem but on the integrated, dynamic relationships among the subsystems of the person. The spiritual drive draws energy from the universe, unifies the subsystems, and gives energy back to the universal energy afield through continual energy exchange. When caring for the person, the nurse does not focus on one subsystem but on the integrated, dynamic relationships among the subsystems of the person. His or her internal model of the world determines the person's perceptions and interpretations of the environment.

Health Health is a holistic sense of well-being. Health is not defined by an absence of disease but rather a state of equilibrium among the subsystems of the holistic person. Included in health are the person's beliefs about the quality of his or her life and ability to find meaning in life and to have a positive future orientation (Erickson, 2010a). The sense of well-being may

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be experienced in the presence of illness. A goal of nursing is to facilitate the client's achievement of perceived optimal health.

Environment The concept of environment was not defined in Erickson's original work but has been described in later publications. The concept includes the client's internal and external stressors as well as internal and external resources. “The theorists see environment in the social subsystems as the interaction between self and others both cultural and individual” (Erickson, 2002a, p. 452). The importance of the interpersonal environment is emphasized in the theory.

How People Are Alike While recognizing the uniqueness of persons, MRM identifies ways in which people are alike: They are holistic, they experience lifetime growth and development, and they have a need for affiliated individuation. In understanding how people are alike and how they are different, Erickson synthesizes a number of interdisciplinary theories identified below.

Holism Dynamic relationships exist among mind, body, emotion, and spirit. Figure 12.1 shows the holistic model of the person. This figure demonstrates the integration of biophysical, psychosocial, cognitive, and social aspects of the person. While identified as separate parts, the figure shows that the multiple subsystems are interconnected and permeated by the genetic base and spiritual drive. Spiritual energy permeates and influences the subsystems while unifying the dimensions of the holistic person. The subsystems interact and function as a total unit.

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Figure 12.1 Model of the holistic person. (From Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling: A theory and paradigm for nursing (p. 45). Englewood Cliffs, NJ: Prentice-Hall. Used with permission.)

Lifetime Growth: Basic Needs People are alike in that they all have basic needs. MRM theory incorporates Maslow's (1968) hierarchy of needs as the framework for understanding basic need satisfaction. Individuals have an inherent desire to fulfill one's potential. Holistic growth is impeded when basic needs are unmet. Consistent with the concept of modeling, the theory supports the view that “all human beings have basic needs that can be satisfied, but only from within the framework of the individual” (Erickson et al., 1983,

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p. 58).

Lifetime Development People are also alike because they mature and develop over the lifetimes. The theoretical support for psychosocial development comes from the work of Erik Erikson (1968). As an individual moves through the eight developmental stages, he or she resolves the tasks or crisis of that stage. Resolution of the developmental stage results in the acquisition of lasting strengths and virtues.

Piaget's (1952) theory provides the framework for understanding how people are alike in their cognitive development. Individuals progress through a series of stages in which the ability to think and reason becomes more complex.

Affiliated Individuation “Individuals have an instinctual need for affiliated individuation. They need to be able to be dependent on support systems while simultaneously maintaining independence from these support systems” (Erickson et al., 1983, p. 47). The need for affiliation motivates individuals to seek support. As the need for affiliation is met through supportive contacts, an “affiliative resource” is developed. A healthy sense of individuation is developed as individuals make independent choices, feel good about themselves, and feel esteem from others (Acton, 1997).

How People Are Different Although people are alike in that they are holistic and share a common process of growth and development, each person is unique. MRM theory identifies these unique aspects of people as the inherent endowment, the ability to adapt, and one's personal model of the world.

Inherent Endowment A person's inherent endowment is comprised of both the genetic base and the inherent characteristics. The genetic base determines, to some extent, how a person progresses through the developmental processes and responds to stressors. The inherent characteristics also influence health and

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growth and development. These characteristics include “malformation, brain damage, or other physiological states secondary to birth, prenatal disease, sicknesses, or other factors” (Erickson et al., 1983, p. 75).

Adaptation People differ in the ability to adapt. Individuals are confronted with stressors, both internal and external on a continuous basis. When the response to these stressors is growth directed, adaptation results. Within MRM theory, adaptation is approached from an integrated perspective. Theoretical support for the physiological response to stressors comes from the work of Selye (1976), particularly the general adaptation syndrome. The psychosocial perspective is supported by Engel's (1962) research on the human response to stressors.

Erickson conceptualized a biophysical–psychosocial model, the APAM that identified states of coping that “reflect an individual's potential to mobilize self-care resources,” the individual's adaptive potential. When a stimulus is experienced as a challenge, it is a stressor, and when experienced as threatening, it is a distressor and leads to a maladaptive response (Barnfather, Swain, & Erickson, 1989b; Erickson & Swain, 1982; Erickson et al., 1983).

Three categories are identified in the APAM: arousal, equilibrium, and impoverishment. As shown in Figure 12.2, the experience of a stressor leads to a state of arousal. Arousal may be experienced by feelings of tenseness and anxiousness, accompanied by elevations in blood pressure, pulse rate, respirations, and motor–sensory behavior. From arousal, the person may move to a state of equilibrium or impoverishment. In a state of impoverishment, the individual experiences marked feelings of tension and anxiety with feelings of fatigue, sadness, or depression. In addition to elevated pulse, respiration, blood pressure, and motor–sensory behavior, there is an elevation in verbal anxiety. Equilibrium may be adaptive or maladaptive. In adaptive equilibrium, the individual has normal vital signs and sensory–motor behavior, expresses hope, and has low or absent feelings of tenseness, fatigue, sadness, and depression. In a state of maladaptive equilibrium, one may appear to be coping with stressors but at the expense of draining energy from another subsystem (Erickson et al., 1983).

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Figure 12.2 Adaptive potential assessment model. (From Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling: A theory and paradigm for nursing (p. 81). Englewood Cliffs, NJ: Prentice-Hall. Used with permission.)

Each state is associated with different coping potentials or different abilities to mobilize coping resources. Movement among the states, either to equilibrium or impoverishment, depends on the ability to mobilize resources and the presence of new stressors. Figure 12.3 shows the relationship among the APAM states. Assessment of the person's adaptive potential provides important information for the nurse as it is an indication of the resources available, the degree to which the person can mobilize the resources independently, and the level at which the nurse needs to intervene to facilitate adaptation. Nursing interventions are directed toward assisting the client to identify, secure, and mobilize resources (Erickson et al., 1983).

Figure 12.3 Dynamic relationships among states of the adaptive potential assessment model. (From Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling: A theory and paradigm for nursing (p. 82). Englewood Cliffs, NJ: Prentice-Hall. Used with

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permission.)

Person's Model of the World: Self-Care Knowledge, Resources, and Action Each person has a unique worldview. Nurses use the process of modeling to develop an understanding of how the person perceives the world from his or her own perspective. One aspect of this “model of the world” that relates to health is self-care knowledge. Each person knows, at some level, what interferes with and what promotes his or her own health and development. This self-care knowledge makes the client the primary source of information in nurse–client interactions. There are two additional self-care concepts related to self-care knowledge. Self-care resources include both internal and external resources that can be mobilized to promote holistic health. Finally, self-care action is the “development and utilization” of self-care knowledge and self-care resources. Activities include both the acquisition of additional resources and the mobilization of self-care resources toward the goal of achieving optimal holistic health. Nursing intervention can assist the client in acquiring and mobilizing resources (Erickson et al., 1983). Figure 12.4 shows the relationship among MRM self-care concepts.

Figure 12.4 MRM self-care concepts. (From Hertz, J. E., & Baas, L. (2006). Self-care: Knowledge, resources, and actions. In H. Erickson (Ed.), Modeling and role-modeling: A view from the client's world (p. 98). Cedar Park, TX: Unicorns Unlimited. Used with permission.)

Description of the Theory of Modeling and Role-Modeling

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Theoretical Linkages MRM theory draws on concepts from several theorists. Each theorist places emphasis on one aspect of the person. However, Erickson's creation of a holistic nursing theory explains the dynamic relationships among basic need satisfaction, growth, developmental processes, loss, grief, and adaptation. The functional relationships among these concepts lead to theoretical linkages. Relationships exist between/among:

Need satisfaction and developmental task resolution Need satisfaction and adaptive potential Need satisfaction, object attachment, and loss, grief, growth, and development Developmental residual and self-care resources (Erickson, 1990, 2002a, 2002b)

Figure 12.5 shows the relationships among the MRM concepts of basic need satisfaction, resolution of developmental tasks, and adaptive potential. For example, the figure demonstrates possible outcomes in adaptive potential when basic needs are met or unmet. When needs are met, the individual is able to mobilize self-care resources and then contend with new stressors that may occur. Satisfaction of basic needs also supports the resolution of developmental tasks, which then result in the individual acquiring positive developmental residual that facilitates the person in demonstrating behaviors that sustain and promote holistic health. However, when the individual fails to have basic needs met, the ability to mobilize self-care resources is compromised leading to difficulty in contending with new stressors. When needs are not met, the person has difficulty in resolving developmental tasks, leading to negative developmental residual and to behaviors that impede holistic health.

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Figure 12.5 Relationships among need satisfaction, resolution of developmental tasks, and adaptive potential.

The relationship between the MRM concepts of need satisfaction and object attachment is shown in Figure 12.6. When objects consistently meet one's needs, secure attachments form, leading to a sense of worthiness and futurity and the ability to mobilize self-care resources. In contrast, when objects fail to consistently meet individual's needs, insecure attachments form. In the case of loss, replacement objects are necessary to help resolve the grief associated with the loss. Lack of a secure replacement object results in a grief response, which is associated with basic need deficits.

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Figure 12.6 Relationships between basic needs and attachment.

Although the concepts presented in the theory, when viewed individually, may seem simple, the interactions among the factors demonstrate the complexity of the theory. When providing holistic care, the nurse is challenged to view the client not only from interactions of multiple subsystems but also from the interacting dynamics of basic needs, developmental processes, attachments, mobilization of resources, and others, to achieve holistic health.

From these theoretical linkages, Erickson identified 13 propositions that can be used to predict outcomes, direct the planning of nursing care, and evaluate care.

1. Individuals' ability to contend with new stressors is directly related to the ability to mobilize resources needed.

2. Individuals' ability to mobilize resources is directly related to their need deficits and assets.

3. Distressors are related to unmet basic needs; stressors are related to unmet growth needs.

4. Objects that repeatedly facilitate the individual in need satisfaction

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take on significance for the individual. When this occurs, attachment to the object results.

5. Secure attachment produces feelings of worthiness. 6. Feelings of worthiness result in a sense of futurity. 7. Real, threatened, or perceived loss of the attachment object results in

the grief process. 8. Basic need deficits coexist with the grief process. 9. An adequate alternative object must be perceived available in order

for the individual to resolve the grief process. 10. Prolonged grief due to an unavailable or inadequate object results in

morbid grief. 11. Unmet basic and growth needs interfere with growth processes. 12. Repeated satisfaction of basic needs is prerequisite to working

through developmental tasks and resolution of related developmental crises.

13. Morbid grief is always related to need deficits (Erickson, 1990, p. 28).

Applications of the Theory in Research MRM has been the theoretical foundation for numerous published research studies, master's theses, and doctoral dissertations. Many of the studies test the middle range concepts found in MRM theory or explore the relationships between or among concepts.

Affiliated Individuation Acton (1997) tested the concept of affiliated individuation to determine its ability to be a mediator between stress and burden of caregivers and caregiver satisfaction with family caregivers of adults with dementia. Acton and Miller (1996) investigated the effects of a theory-based support group intervention on affiliated individuation with a group of caregivers of adults with dementia. The relationships among of quality of life (QOL), self-care, and affiliated individuation in persons receiving warfarin therapy were studied by Goldstein (2014). The study served as validation for

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Acton's research indicating the value of affiliated individuation as a self- care resource.

Adaptive Potential Assessment Model The APAM was first tested by Erickson (1976).

Erickson and Swain (1982) studied the model to statistically validate the three categories of the APAM—arousal, equilibrium, and impoverishment—and to determine whether a relationship existed between the categories and the length of hospital stay. Further testing of the validity of the model was conducted by Barnfather et al. (1989a) to determine if subjects could be classified into the three adaptive states, as a measure of ability to mobilize coping resources. Barnfather (1987) applied the APAM to healthy subjects to test the relationship between basic need satisfaction and the ability to mobilize coping resources. In another study, Barnfather (1993) conducted additional testing of the model and the relationship between basic need status and adaptive potential with male students experiencing stress.

Health/Well-Being Research conducted by Irvin and Acton (1996) tested a model of caregiver stress mediation to determine if perceived support and self-worth had a mediating effect on well-being. Acton and Malathum (2000) studied the relationship between basic need satisfaction and health-promoting behavior and determined the best predictors of health-promoting self-care behavior. The relationship between basic need satisfaction and emotional eating was studied by Timmerman and Acton (2001). They found that a lower level of need satisfaction was associated with increased emotional eating. “The findings of this study support the proposition from the conceptual framework [MRM] the individuals with higher levels of basic need satisfaction will be better able to deal with stress and thus, engage in healthier behaviors” (p. 699).

Self-Care Resources/Actions

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Erickson and Swain (1990) conducted a nursing intervention study with hypertensive clients to determine the efficacy of MRM-based interventions directed toward mobilizing self-care resources. Irvin (1993), identifying social support, self-worth, and hope as self-care resources, studied the relationships among these resources and caregiver stress. Using hope as a self-care resource, Irvin and Acton (1997) studied stress mediation in women caregivers, testing ways that stress and well-being were affected by self-care resources. The purpose of Rosehow's (1992) research was to identify self-care actions perceived as significant for persons 6 months after myocardial infarction. Preferences and rankings of self-care actions were also identified. Baldwin, Hibben, Herr, Lohmer, and Core (2002) investigated the perception of self-care in an Amish community.

Research by Baas (1992) identified the predictor variables related to self-care resources on life satisfaction in persons following myocardial infarction. The concept of self-care resources was also studied in its relationship to QOL (Baas Fontana, & Bhat, 1997). The researchers conducted an exploratory pilot study with individuals diagnosed with heart failure to determine potential differences among the groups in measures of self-care needs, resources, and QOL. Baas (2004) reported the results of an ex post facto correlational study focused on self-care resources as a predictor of the QOL of persons 3 to 6 months following an MI. She found that “most of the explained variance in QOL was predicted by self-care resources that were perceived available” (p. 136).

A new concept, perceived enactment of autonomy (PEA), was developed based on the concept of self-care (Baas, Curl, Hertz, & Robinson, 1994; Hertz, 1991). PEA is conceptually defined as “a state of sensing and recognizing the ability to freely choose behaviors and courses of action on one's own behalf and in accordance with one's own needs and goals” (Hertz, 1995, p. 269). The results of two studies of older adults living in the community “supported a theoretical relationship between PEA and selected self-care health indicators” (Hertz & Anshultz, 2002, p. 179). PEA was shown to be significantly related to self-care knowledge, concepts of life satisfaction, and perceived control.

The investigation of MRM self-care concepts with children has been the focus of three dissertations. Baldwin (1998) studied the effects of a self-care health curriculum on third-grade students' overall health care characteristics and self-care actions. In this study, self-care subconcepts were identified as hope, control, satisfaction with daily life, support, and physical health. The research demonstrated that the group that received the

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self-care curriculum had higher mean scores of hope and satisfaction with daily living. Nash (2003) studied the impact of the Empowerment Program on self-care resources of middle school–aged children. In another study of middle school–aged children, Bray (2005) investigated the two theoretical propositions of MRM: the relationship between resolution of developmental tasks and need satisfaction and the relationship of need satisfaction to coping ability. Self-care resources identified in the study included motivation, engagement, and interpersonal relationships. The study supported the relationship between measures of health and self-care resources as well as the significance of self-care resources in explaining variances in health.

Other Studies Additional studies, not related to the categories of concepts, included above-employed MRM as the theoretical foundation. Examples of the concepts researched are comfort (Kennedy, 1991), compassionate visiting (Holl, 1992), psychophysiological processes of stress (Kline, 1988), uncertainty, spiritual well-being and psychological adjustment to illness (Landis, 1991), unmet needs of persons with chronic mental illness (Perese, 1997), psychological development and coping ability (Miller, 1986), and nurse–patient interactions (Rogers, 2002). Using Middle Range Theory in Research Boxes 12.1 through 12.3 provide examples of research examining the effectiveness of MRM with individuals in assisted-living situations, with community-living older adults, and with women diagnosed with factitious disorder.

USING MIDDLE RANGE THEORY IN RESEARCH 12.1

Source: Staus, R. (2010, April). Culture change in an assisted-living facility: A MRM approach. Presentation at Facilitating Spiritual Well- Being: The Society for the Advancement of Modeling and Role- Modeling Biennial Conference, San Antonio, TX.

Research Purpose/Question

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MRM theory served as the theoretical foundation for this Doctor of Nursing Practice project. The focus of this project was to determine the effect of a culture change intervention that utilized nursing-directed activities, person-centered care plans, and integrative interventions on perceived QOL from the perspective of elders, families, and nursing staff in an assisted-living facility.

Intervention MRM theory was clinically applied through the use of the “I” care

plan, based on a personal relationship with the client, the client's model of the world, and unique interventions designed to meet the needs of the client. In addition to the individualized care plans, a Plan–Do–Study– Act cycle was utilized to plan meaningful, growth-promoting activities for residents. Integrative therapies were included as part of the services offered to residents.

Evaluation Measures Culture change was measured through the use of the Artifacts of

Culture Change instrument. An observational tool, the Observable Indicators of Nursing Home Care Quality Indicators, was used to evaluate the health promotion program. Finally, Quality of Life surveys (adapted from Ohio KePRO) were administered. Post–project review of the residents' Culture Change tool and Quality of Life indicated a “marked increase” in measures of quality of life. The Artifacts of Culture Change organizational tool showed an increase of 18% on the domain of care practices and a 22% increase in the domain of outcomes.

Conclusions The project highlighted the importance of person-centered care in

assisted living, an area often neglected. In addition, the project focused on combining evidence-based approach to change with a solid foundation in nursing theory. This project won a national “Promoting Excellence in Assisted-Living Person-Centered Care Award” from the Center for Excellence in Assisted Living and first place in the Evidence-Based Practice category at the Midwest Nursing Research Society Annual Conference.

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USING MIDDLE RANGE THEORY IN RESEARCH 12.2

Source: Matsui, M., & Capezuti, E. (2008). Perceived autonomy and self-care resources among senior center users. Geriatric Nursing, 29(2), 141–147.

Research Purpose The purpose of this study was to examine the relationship of PEA

with internal and external self-care resources (MRM-based concepts) of community-based older adults.

Research Design Descriptive correlational

Sample/Participants Participants (n = 120) were recruited from six Manhattan senior

centers.

Data Collection Participants completed three instruments that measured study

concepts of autonomy, social support, and functional status. The instruments used in the study were the Hertz Perceived Enactment of Autonomy Scale (HPEAS), the Multidimensional Scale of Perceived Social Support (MPPSS), and the Barthel Index (BI).

Findings Researchers found that participants had high scores on the HPEAS,

indicating positive perceived autonomy. Functionality scores, measured by the BI, indicated that as a group, the participants were highly independent. Function was highly correlated with perceived autonomy. External self-care resources, satisfaction with services, and social support were significantly connected to perceived autonomy as were internal self-care resources. When discussing the implications of the findings for practice, the researchers caution against nurses' use of actions or language that may discourage self-care. They suggest that nurses engage in activities that increase the client's perception of control

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such as providing information that supports informed decision making and independent action.

USING MIDDLE RANGE THEORY IN RESEARCH 12.3

Source: Koren, M. E., & Papamiditriou, C. (2013). Spirituality of staff nurses: Application of modeling and role-modeling theory. Holistic Nursing Practice, 27(1), 37–44. doi: 10.1097/HNP.0b013e318276fc38.

Purpose/Research Question What is the role of spirituality in the daily work of staff nurses?

MRM theory served as a foundation for conceptualizing spirituality as well as a framework for data analysis.

Research Design Descriptive qualitative The role of spirituality in the daily work of staff nurses was

examined in this descriptive qualitative study.

Sample/Participants Nurses were recruited from a 400-bed suburban community

hospital. Eleven nurses participated in one of two focus groups.

Data Collection Audio-recorded focus groups were used to collect in-depth

information about nurses' spiritual needs and the barriers and facilitators of spirituality in the work environment.

Findings Content analysis using a constant comparative methodology was

applied to data to develop and refine categories, common themes, critical exceptions, and relationships across categories and themes. Nurses reported experiencing spirituality in the care of patients through finding meaning and purpose in the work, through establishing

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relationships with patients, and through providing meaningful care to patients. Nurses also identified self-care as an issue; after caring for patients, there was little time to focus on their own needs.

MRM concepts of internal and external resources were used to categorize the nurses' responses. Internal resources were the motivation or drive to do the work, unique to each individual. External resources (facilitators) were identified as the people or things that offered support such as a blessing of the hands ceremony, a memorial services, and debriefing sessions. The external resources (barriers) were things that could be improved in the work environment, for example, a mechanism to discuss daily issues with other nurses.

The results of the study support providing time for nurses to reflect on their practice, the continuation of special ceremonies with a spiritual focus, creation of support groups, and visits to the nursing units from nursing leaders in the organization.

Instruments Used in Empirical Testing Several instruments have been developed to test MRM theory. Table 12.1 lists instruments that have been used in MRM research.

Table 12.1 Instruments Commonly Used in MRM Research

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Application of the Theory in Practice

Paradigm for Nursing Practice The practice paradigm of MRM is presented within the framework of the nursing process, emphasizing the importance of both the interactive, interpersonal nature of nursing and the theoretical and scientific bases of nursing practice. Nursing care begins with the initial nurse–client contact. The nurse starts by determining the client's model of the world and then focusing on the most immediate concerns expressed by the client. The practice paradigm directs data collection, data aggregation, analysis, and synthesis and provides a framework for planning nursing interventions. Critical thinking is required to implement these activities.

Consistent with the concept of modeling, the client is viewed as the primary data source. The nurse and family members are secondary data sources and the rest of the health care team are the third data source. The nurse looks for congruence between data received from the client and that received from significant others and health care professionals. Data are collected and organized in the following categories:

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Description of the situation—to develop an overview of the client's perspective of the situation Expectations—to determine the client's expectations for the future Resource potential—to determine internal and external resources available to the client Goals and life tasks—to determine developmental status and personal model of the world (Erickson et al., 1983)

Erickson (2010b) has described strategies, done within the context of unconditional acceptance, that facilitate a trusting relationship with the client. This relationship is the basis for implementation of interventions. The first strategy is “establishing a mind-set” (p. 216). This involves centering in the present moment and setting the intent to nurture and facilitate the client's healing. The second strategy involves “creating a nurturing space” or creating a healing environment. “It is important to remember that you are entering the client's space and to respect it” (p. 217). The third strategy is “facilitating the story.” Active listening is used to understand the client's self-care knowledge. Kinney (2006) emphasizes the importance of connecting heart-to-heart with the client. “The more conscious we are in our intent to create heart-to-heart relationships, the more we connect spirit-to-spirit with our clients, facilitate their ability to connect with their Soul, and experience holistic growth and healing” (p. 278). The client example in Using Middle Range Theory in Practice 12.4 demonstrates application of MRM concepts in practice.

USING MIDDLE RANGE THEORY IN PRACTICE 12.4

Source: Swanson, E. (2015). Heart gut head: Creating a healthier hierarchy (pp. 6–7). Edina, MN: Beavers' Pond Press, Inc. (Reprinted with permission from Ellen Swanson.)

Problem “To cope with the advancing symptoms of Alzheimer's disease, Eve

had moved to assisted living from a senior independent apartment. Two of her greatest pleasures in life had been dancing and driving. She described trips where she drove and her husband sat in the passenger

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seat and worked or read. They regularly spent evenings at a local ballroom, dancing the night away. After he died, she was lonely. Eve needed some outings that didn't require the complexity of socializing, in addition to needing a health-care advocate, so I was called in. Our outings gave us an opportunity to incrementally build a trusting relationship, a definite need for someone with no children and no family in the area. Partially because of her ‘aloneness,' Alzheimer's understandably brought on some paranoid tendencies. This provided specific challenges in building a trusting relationship. As a strategy to help us overcome those challenges, our shared outings had therapeutic value.”

Nursing Intervention “It was not easy to find outings that were meaningful to Eve. When

she walked with a walker and could no longer drive, how could I connect through dancing or driving? One day we drove past a huge empty church parking lot. I pulled into the parking lot, put a tape on the tape deck, and turned up the music that she and her husband had danced to in their youth, the big band sounds of World War II. I invited her to put both hands over onto the steering wheel. I told her we were going to dance the car. She rhythmically and slowly turned the steering wheel, closed her eyes, and allowed a huge smile to slowly spread across her face. She (we) danced the car safely in this huge empty parking lot. When she eventually opened her eyes and released the steering wheel, she was visibly relaxed and happy. This became a favorite outing, promoting connection and relaxation, practicing presence, and dancing with resonance.”

Outcome This nurse–client interaction reflects application of MRM concepts. As a care manager and client advocate, the nurse established a heart-to-heart, trusting relationship while demonstrating unconditional acceptance and seeking to understand the client's model of the world. The intervention that was chosen, not a “standard” intervention, was based on the client's model of the world and the nurses understanding of nursing science and nursing theory. It facilitated need satisfaction and promoted the client's positive

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orientation and control. The use of standardized nursing interventions is not consistent with

MRM beliefs. The theory does provide general aims of interventions that are associated with the principles of the theory and facilitate the planning of systematic interventions. These are to build trust, promote client's positive orientation, promote client's control, affirm and promote client's strengths, and set mutual goals that are health directed. Table 12.2 shows the aims of intervention and the MRM principle associated with each intervention. Modeling and Role-Modeling: A Theory and Paradigm for Nursing (Erickson et al., 1983) provides specific examples of how the aims of interventions can be linked to basic need satisfaction. In the implementation of nursing interventions, the goal is to carry out one intervention that reflects each aim during every contact with the client. A single intervention can meet more than one of the general aims of intervention. Selected publications that demonstrate the application of MRM theory in practice are presented in Table 12.3.

Table 12.2 Relationship Between Aims of Intervention and MRM Principles

Source: Erickson et al. (1983, p. 170).

Table 12.3 Examples of Theory in Practice

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Utilization of MRM Theory in Nursing Education and Practice MRM theory serves as a foundation for nursing education in several nursing programs. Table 12.4 lists the programs using MRM ranging from integration in specific courses to serving as the foundation for the curriculum. Nurses in many settings who have been exposed to MRM either through the literature or as students have introduced the concepts into their practice environments formally or informally. It is difficult to state the overall impact of the theory on nursing practice. Thousands of students have been introduced to the theory. At Metropolitan State University, RN-BSN students completing the theory course are asked to state ways in which MRM theory has impacted their nursing practice. The following statement is representative of comments from many students. “MRM has taught me to delve into the more holistic perspective in caring for my patients. I have learned to be more self-aware and to view the medical world from a different angle – that of my patient. This will enable

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me to change my perspective of nursing to incorporate mind, body, and spiritual healing” (Yang cited in Schultz, 2010, p. 225).

Table 12.4 Nursing Programs Utilizing Modeling and Role-Modeling Theory

Source: Erickson (2010b), Gryczman (personal communication, 2010), mrmnursingtheory.org.

The literature provides examples of planned integration of MRM theory in health care facilities. Alligood (2011) described integrating MRM theory at the University of Tennessee Medical Center, Knoxville. The theory was selected as “based on its capacity to facilitate delivery of quality care, simplify language, improve communication, clarify decision making and save time” (p. 982). Nurse-managed wellness clinics for older adults have been established by faculty at Duquesne University School of Nursing based on the MRM holistic paradigm. Students participating in the clinic use MRM theory as a foundation for nursing interventions (Resick, Taylor, & Leonardo, 1999; Resick, 2014). MRM theory was integrated into nursing practice at Brigham and Women's Hospital as part of an organizational change process (Ponte, Higgins, James, Fay, & Maddenen, 1993). Nurses on a surgical unit at the University of Michigan developed

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http://mrmnursingtheory.org

and implemented an assessment tool that is based on MRM (Campbell, Finch, Allport, Erickson, & Swain, 1985; Finch, 1990; Walsh, VandenBosch, & Boehm, 1989); the nurses in the vascular surgery unit use MRM as their practice framework (University of Michigan, 2002). Health care facilities across the country that are currently using MRM theory as the foundation for nursing practice are listed in Table 12.5.

Table 12.5 Health Care Facilities Implementing MRM Theory in Nursing Practice

Source: Erickson (2010b), Johnson (personal communication, 2010), mrmnursingtheory.org, Resick (2014).

The Society for the Advancement of Modeling and Role-Modeling (SAMRM) was established to advance the development and application of the theory by promoting the study and integration of the theoretical propositions and philosophical underpinnings, developing a support network, disseminating knowledge and information, and promoting the improvement of holistic health (Bylaws, 2010). The society has sponsored biennial conferences since 1986 and provides grants to support the testing, development, or implementation of MRM theory or concepts. SAMRM maintains a website (www.mrmnursingtheory.org) and publishes a newsletter quarterly.

Summary MRM theory is a holistic nursing theory derived from nursing practice and continues to be the foundation for practice, nursing education, and research. The client is central in the theory; MRM may be unique in the identification of the client as the primary source of data.

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http://mrmnursingtheory.org

http://www.mrmnursingtheory.org

The theory is organized according to concepts that relate to the role of the nurse including modeling, role-modeling, facilitation, nurturance, unconditional acceptance and nursing, and those that relate to person (human nature), such as health, holism, environment, lifetime growth and development, affiliated individuation, adaptation, and self-care. The two central concepts of the theory are modeling, in which the nurse develops an understanding of the client's view of the world from the client's perspective, and role-modeling, guiding the nurse to develop interventions unique to the client and based on nursing science and theory. Research has demonstrated the relationship between and among the foundational (support theory) concepts of need satisfaction, developmental task resolution, object attachment, and self-care resources. The interactive, interpersonal nature of the relationship with the client requires a “heart-to-heart connection” and the use of therapeutic communication skills to elicit the client's model of the world. The theory provides a framework for collecting and organizing client data and 13 propositions for interpreting the data and plan nursing care. Five aims of intervention provide direction for the development of specific nursing interventions. Due to the number of concepts integrated into the theory, MRM supports research in multiple areas including adaptation, health, self- care resources, and self-care actions. MRM theory has been implemented in clinical practice in a wide range of situations such as major health care systems, community clinics, assisted-living facilities, and individual client care. The literature reflects using MRM in planning nursing care for clients with depression, obesity, Alzheimer's, factitious disorder, and others.

Critical Thinking Exercises

1. The APAM identifies states of coping as arousal, equilibrium, and impoverishment. Consider a client for whom you are caring. Given a specific nursing diagnosis, how would your nursing interventions differ depending on the adaptive state of the client?

2. The client's model of the world is a primary concept in MRM. Using the assessment data that you have compiled about a client, write a description of the client's model of the world in the “first person.”

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3. MRM was developed for application to an individual client. Can MRM be applied to the family? Does a family have a model of the world, an adaptive state, and developmental stages, for example?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the MRM theory.

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13 Comfort Katharine Kolcaba

Definition of Key Terms

Comfort The immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, sociocultural, and environmental); much more than the absence of pain or other physical discomforts.

ComfortPlace™ An institution practicing a philosophy of health care that focuses on addressing physical (including homeostatic mechanisms as well as sensations), psychospiritual, sociocultural, and environmental comfort needs of patients, families, and nurses. This type of health care has three components: (a) appropriate and timely comfort interventions, (b) delivery of comfort interventions that conveys caring and empathy, and (c) the intent to comfort. All components are based on an in-depth understanding of the patient's medical history and current medical problems, the family's needs for information or hope or a place to rest, and/or an institution's resolve to improve its working environment.

Comfort interventions Skilled actions of the health care team intentionally designed to enhance patients' or families' comfort. Also, changes in the health care environment that enhance the comfort of nurses.

Comfort needs Patients' or families' desire for or deficit in relief/ease/transcendence in physical, psychospiritual, sociocultural, and environmental contexts of human experience.

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Health-seeking behaviors (HSBs) Behaviors in which patients, families, or nurses engage consciously or subconsciously moving them toward well-being; HSBs can be internal, external, or dying peacefully (when that is the most realistic option for patients).

Institutional integrity (InI) The quality or state of health care organizations as complete, whole, sound, upright, professional, and ethical providers of health care.

Intervening variables Positive or negative factors over which the health care team has little control, but which affect the direction and success of comfort care plans, comfort studies, or comfort interventions. Examples are presence or absence of social support, poverty, positive prognosis, concurrent medical or psychological conditions, health habits, environmental design, administrative philosophy, and so on.

Introduction The concept of comfort has had a historic and consistent association with nursing. Nurses traditionally provide comfort to patients and their families through actions that, in this theory, are called comfort interventions. The theory of comfort, as applied in a ComfortPlace™, explicates a philosophy of care whereby holistic comfort needs of patients, families, and nurses are identified and addressed. Intervening variables are accounted for in planning and assessment. The desired and immediate outcome of this type of care is enhanced comfort, an altruistic and patient-centered goal. Later, Kolcaba expanded this desired outcome to apply to nurses and other members of health care teams. This application is useful when institutions are applying for national designations, such as Magnet Status from the American Association of Certification for Nurses, the American Association of Critical Care Nurses Beacon Award, or the Gold Seal of Approval from the Joint Commission Association for Health Care Organizations. In addition, enhanced comfort is related to subsequent desirable outcomes such as higher patient or nurse function, quicker discharge, fewer readmissions, increased satisfaction with care, longevity of employment, and stronger cost–benefit ratios for the institution. These

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subsequent outcomes provide additional rationale for health care leaders and teams to adopt a model of comfort as a unifying framework for care delivery.

Historical Background Nightingale was perhaps the first health care worker to recognize that comfort was essential for patients. She said, “It must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort” (Nightingale, 1859), p. 70). In this quote, Nightingale implied that the relationship between health and comfort is strong and direct and that both are equally important.

At the beginning of the 20th century, the term comfort was used in a general sense, much as Nightingale had used it, and comfort was highly valued in nursing. Moreover, the ability to provide comfort determined, to a large degree, the nurse's skill and character.

At this time, nurses believed that the provision of comfort was their unique mission. Comfort was especially important because curative medical strategies were not yet developed. Enhancing patient comfort was seen as a positive nursing goal that also was strengthening and, in most cases, should entail an improvement from a previous state or condition. Comfort resulted from physical, emotional, and environmental interventions, but orders for specific comfort measures were under the physician's authority. Some common “comfort orders” in this period were for poultices, heat, and positioning of the patient in bed (McIlveen & Morse, 1995).

Although emotional care was not one of the specified roles of nurses, physical comfort interventions were intended to bring about mental comfort of patients, indicating that physical and mental comfort were closely related. In early nursing texts, the meaning of comfort was implicit, hidden in context, complex, and general. Many semantic variations, such as comforting, to comfort, in comfort, and comfortable, were used, and the term could be in the form of a verb, noun, adjective, or adverb. Comfort also referred to the process of comforting (“The nurse comforted the patient”) or the outcome of comfort (“The patient was comforted by the nurse”).

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By the middle of the 20th century, comfort evolved to a less important nursing goal with a connotation more specific to the physical sense. In the 1950s, as analgesics became popular for pain control, few additional treatments for comfort were described (McIlveen & Morse, 1995). At this time, nurses took responsibility for patients' feelings, although nurses were told to refrain from discussing patients' medical conditions with them.

In the 1950s and 1960s, the term remained undefined for nursing, and it was narrowly interpreted, written about rarely, and, of course, not measured or documented. These conditions rendered comfort interventions by nurses, and the results on comfort of patients, invisible.

The 1980s saw many advances in medicine, and cures often resulted from surgery, antibiotics, radiation therapy (RT), and chemotherapy. Narcotics were used for treating severe pain. The importance of family comfort began to emerge at this time, and families were considered legitimate recipients of care and comfort interventions (McIlveen & Morse, 1995). Correlation between the comfort of patients and the comfort of their families was implied.

Also, during the 1980s, nurses promoted self-care for patients whenever possible. Comfort was the main goal of nursing only when patients were terminally ill, an observation that supported Glaser and Strauss' (1965) earlier suggestion that the goal of nursing reverted to comfort when there were no available cures. Where health care settings were less influenced by technology, such as hospice and long-term care, comfort was more important as a nursing goal. McIlveen and Morse (1995) suggested that this trend had broad implications for nursing in the twenty-first century, as demographics would shift to large numbers of elders who may wish for less technology and more comfort in their last years of life.

Definitions of Theory Concepts When a concept is germane to a discipline, as comfort is, but it has not yet been specifically defined, a concept analysis is necessary. Thus, in 1988, this task was undertaken by Kolcaba. It began with a study of several contemporary dictionaries, each of which contained six or eight definitions of comfort. Those meanings were compared to usages found in an extensive literature search in the journals and textbooks of several

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disciplines (nursing, medicine, theology, ergonomics, psychology, and psychiatry). From ergonomics came the insight that comfort of persons, for example, in their workplace or their cars, was important for optimum function or productivity (Kolcaba & Kolcaba, 1991). Kolcaba extended this insight to patients and their families.

Also consulted for the concept analysis were nursing history books and the Oxford English Dictionary (OED), which traces the origins and evolution of English words. In 1988, the nursing diagnosis (NANDA) for altered comfort was limited to specific physical discomforts such as pain, nausea, and itching. In nursing textbooks, comfort was discussed in terms of pain management. But the origins of comfort supported a significant association with strengthening, because the concept itself came from the Latin word confortare, which means “to strengthen greatly.” That obsolete meaning of comfort, not included in modern dictionaries, was still very appropriate for nursing! From the OED, the following definitions of comfort were explicated: (a) strengthening; encouragement, incitement, aid, succor, support and (b) physical refreshment or sustenance; refreshing or invigorating influence (Kolcaba & Kolcaba, 1991). These meanings, and the link to optimum function in the ergonomic literature, provide theoretical significance for comfort in nursing.

From this process, which took 2 years, three technical types of comfort were derived and labeled: relief, ease, and transcendence (Kolcaba & Kolcaba, 1991).

Relief defined as the experience of a patient who has had a specific comfort need addressed; its theoretical background was consistent with Orlando's (1961/1990) need-based philosophy of nursing. Ease defined as a state of calm or contentment; its theoretical background was enriched by the writings of Henderson (1978) about 13 essential human requirements. Transcendence defined as the state in which one rises above problems or pain. Transcendence was a term previously used in the nursing literature by two psychiatric nurses to denote “more being” achieved through relationships with nurses (Paterson & Zderad, 1976/1988). More being was deemed important for “rising above” or “working through” difficult situations or symptoms.

The analysis was comprehensive but not particularly welcomed by American journals. After presenting these three types of comfort at a research conference, audience feedback was so stimulating that, in the

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middle of the night, Kolcaba awoke with the idea that the types of comfort (relief, ease, and transcendence) occurred physically and mentally. She sketched out a preliminary grid with the three types of comfort across the top and physical and mental down the side. Thus, there were six cells in this first grid. After presenting this preliminary grid to colleagues and professors at Case Western Reserve University (where she was a doctoral student), Kolcaba was advised that her “physical” and “mental” categories were not holistic, and to go back to the nursing literature to discover how holism was conceptualized. Doing so took another year.

Four contexts of holistic experience were subsequently derived from the literature and were labeled physical, psychospiritual, social, and environmental (Kolcaba, 1991):

Physical comfort pertained to bodily sensations and homeostatic mechanisms. Psychospiritual comfort pertained to the internal awareness of self, including esteem, sexuality, and meaning in one's life; it also encompassed one's relationship to a higher order or being. Social comfort pertained to interpersonal, family, and societal relationships (later, this term was changed to sociocultural comfort and family/cultural traditions, and financial circumstances were added to the definition). Environmental comfort pertained to the external background of human experience; it encompassed light, noise, ambience, color, temperature, and natural versus synthetic elements. Environmental comfort did not include energy fields at this time.

When the three types of comfort were juxtaposed with the four contexts of experience, a 12-cell grid or taxonomic structure (TS) was created (Fig. 13.1) (Kolcaba, 1991). The grid depicted the defining attributes of comfort and was helpful for deriving the technical definition of comfort (provided at the beginning of this chapter). The technical definition of comfort is the immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psychospiritual, sociocultural, and environmental) (Kolcaba, 1992). This grid has been useful for assessing comfort needs of patients, families, and nurses; planning interventions to address those needs; informally evaluating the effectiveness of those interventions to enhance comfort; and measuring the desired outcome of enhanced comfort for research and practice.

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Figure 13.1 Taxonomic structure of comfort.

Description of Theory: Major Components and Their Relationships

Assumptions Assumptions are a theorist's point of view about reality, stated clearly so that future readers know where the theorist is “coming from.” Kolcaba's (1994) assumptions are as follows:

Human beings have holistic responses to complex stimuli. Comfort is an immediate and desirable holistic state of human beings that is germane to the discipline of nursing. Human beings strive to meet, or to have met, their basic comfort needs. It is an active endeavor.

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Concepts Concepts are ideas that make up the building blocks of specific theories. The concepts for the middle range theory of comfort are those listed and defined at the beginning of this chapter: comfort needs, comfort interventions, intervening variables, enhanced comfort, health-seeking behaviors (HSBs), and institutional integrity (InI). Consistent with middle range theories, these concepts are at a low level of abstraction (easily defined and measured) and are limited in number. All of these above concepts are relative to patients, families, and nurses; the term family encompasses significant others as determined by the patient (Kolcaba, 2003; Kolcaba, Tilton, & Drouin, 2006b).

Figure 13.2 is a diagram that shows three levels of abstraction from highest (at the top of the diagram) to lowest (at the bottom of the diagram) —a depiction called a substruction. This particular diagram served as the organizing framework for Kolcaba's dissertation study with women going through RT, discussed later in this chapter. Such diagrams are helpful for planning research studies; they are used in many of Kolcaba's articles and on her Web site (Kolcaba, 1997).

Figure 13.2 Theoretical framework for comfort theory. (Source: Kolcaba, K. (2002). Conceptual framework for comfort theory. Retrieved November 11, 2007, from http://thecomfortline.com/conceptualframework.html)

Propositions

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http://thecomfortline.com/conceptualframework.html

Propositions are relational statements that link concepts together. At the middle range level (Fig. 13.2, Line 1), the following propositions link those respective variables (Kolcaba, 2001):

1. Nurses and other members of the health care team identify comfort needs of patients and their family members, especially those needs that have not been met by existing support systems. Nurses also identify their own comfort needs in their workplaces and work constructively for the fulfillment of these needs.

2. Comfort interventions are designed and coordinated to address those unmet comfort needs.

3. Intervening variables are taken into account in designing interventions and determining their probability for success.

4. When interventions are effective, and delivered in a caring manner, the immediate outcome of enhanced comfort is attained.

5. Patients, nurses, and other members of the health care team agree upon desirable and realistic HSBs.

6. If enhanced comfort is achieved, patients, family members, and/or nurses are strengthened to engage in HSBs, which further enhances their comfort.

7. When patients and their family members engage in HSBs as result of being strengthened by comfort interventions, patients, families, and nurses are more satisfied with health care and demonstrate better health-related and institutional outcomes.

8. When patients, families, and nurses are satisfied with health care delivery in a specific institution, improved outcomes and public acknowledgement about the institutions' contributions to health will contribute to those institutions remaining successful.

Comfort theory (CT) can be adapted to any health care setting, health care discipline, or age group, whether in the home, hospital, or community. For research or practice, the concepts can be further defined, at a lower level of abstraction, in terms of specific populations.

Practice Applications

Individuals

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CT has been used to assess the comfort needs of patients and their families, to develop interventions to address those needs, and to evaluate their effectiveness for increasing recipients' comfort (Kolcaba, 1997). It also provides an ethical perspective for decision making in difficult health care situations. For example, when families are faced with difficult choices for their dying loved ones, it is helpful to consider what will make the patient more comfortable (Kolcaba, 2003).

Health Care Systems CT can be adopted throughout an agency, health care system, private practice, or college of nursing to establish criteria for innovations in orientation for new employees, unified research programs, compassionate and value-based care, needs assessment for patients or personnel, actions to take to improve quality, electronic documentation, evaluation of progress toward goals, and/or performance review. For instance, CT has been used by nurse educators as a framework to enhance learning environments for student nurses (Goodwin, Sener, & Steiner, 2007). The theory also has been used by nurse leaders to enhance working environments, especially for nurses, and for working toward national institutional recognitions (Kolcaba et al., 2006b). As a quality improvement initiative, CT has been utilized as a framework for raising patient satisfaction scores as developed by the Hospital Consumer Assessment of Healthcare Providers Service (HCAHPS). These scores are federally mandated from every hospital for the purpose of comparison on an open Web site. Using Middle Range Theory in Practice 13.1 provides an example of how the theory was used as a framework for raising retention rates and nurse satisfaction scores and patient satisfaction scores using the survey developed by the HCAHPS.

USING MIDDLE RANGE THEORY IN PRACTICE 13.1

Source: Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. The Journal of Nursing Administration, 36(11), 538–544.

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Problem The hospital nursing leadership had as its goal enhancing the work

environment, an all-important aspect in achieving Magnet© status.

Intervention The intervention involved two consulting visits with Kolcaba. Prior

to the consultations, efforts were made to promote the theory, primarily through education to the basic elements of comfort theory (CT) and its application to clinical practice. Among the actions taken were the following:

1. Dissemination of the book Comfort Theory and Practice to all units in the hospital

2. Use of a color theme for all communications that matched the cover of the book

3. Creation of bookmarks with the date of the workshop and brief excerpts from the book

4. Distribution of business-sized cards with a reminder of the workshop dates

5. Provision of pins for staff that stated, “Ask me about Comfort” 6. Invitation of faculty from area nursing schools and nursing

leadership to attend a reception with the author 7. Collection of data from an informal survey of various personnel

(health care and ancillary), asking how they brought comfort to patients and families

8. Inclusion of each person's name, picture, and their comments from the survey on large color-coordinated posters

The campaign spanned several months and reached all levels of the health care organization.

At both consultations during breakfast and lunch sessions, Kolcaba presented the clinical staff a brief overview of the theory, focusing on two major themes: (a) enhancing the comfort of nurses through environmental changes, which would encourage nurses and other valued employees to remain with the institution and participate in the entire culture, and (b) enhancing the comfort of patients and their families during hospital stays.

In addition, Kolcaba and the CNO conducted brainstorming session with clinical staff on each nursing unit. One goal of these meetings was

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to identify strategies for enhancing the nursing work environment. Nurses were encouraged to write down ideas for a “wish list” of changes that would create a more comfortable work environment. Another goal was to discuss comfort interventions to be used with patients to increase their comfort. Kolcaba emphasized the importance of assessment and documentation before and after comforting interventions is essential to implementing CT. Documentation provides evidence of the effectiveness of the implementation of the theory. The theory Web site was identified as a resource for guidelines to document and assess the comfort needs of patients and families, design interventions to meet those needs, and evaluate their comfort postintervention for practice or research.

Outcomes Some specific organizational and unit-based initiatives resulted:

1. The nursing philosophy was modified to emphasize physical, environmental, sociocultural, and psychospiritual comfort for both patient/families and nurses. In addition, new objectives in the nursing strategic plan were specifically devoted to increasing the comfort of nurses through promoting a healthier, more comfortable work environment.

2. Orientation for new staff members was updated to integrate CT throughout the process. Core orientation competencies were included that used CT for assessment, intervention, and evaluation of patients' levels of comfort.

3. The theory was used as the foundation of clinical performance evaluation criteria of nurses.

4. Staffing patterns were reviewed and modified to further promote comfortable and safe work environments.

5. Comfort was considered when evaluating equipment for purchase.

The outcomes of these measures were encouraging, nursing turnover and vacancy rates declined and were significantly below state benchmarks, and nurse satisfaction rates increased.

In addition, to promote patient comfort, patient satisfaction surveys were administered. In response, the hospital expanded its service recovery program, involved consumers on committees, and revised the patient/family booklet. As a result, patient satisfaction scores rose.

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Other Disciplines March and McCormack (2009) determined that slight modifications of CT could render it suitable for the thinking and work of other health care disciplines. Recommended modifications were primarily those of vocabulary inclusiveness, such as changing the words from “theory for nursing” to “theory for health care.” Such changes were made on Kolcaba's Web site to facilitate coordinated usage of CT for interdisciplinary communication, assessment, planning, and evaluation throughout a given hospital, health system, or agency. Table 13.1 includes examples of research that supports the use of CT for different patient populations and practicing nurses.

Table 13.1 Examples of Research for Application to Practice

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Research Applications for the Theory of Comfort Generally, in an experimental design, patients meeting inclusion criteria are randomly assigned to levels of intervention such as a usual care group, an intervention group, and/or an enhanced intervention group. Researchers use the General Comfort Questionnaire (GCQ) as a starting point, removing items that are not relevant to their research setting or population and adding items that are relevant. They plot all items on the TS, making sure that the content domain of comfort is evenly represented. Similar numbers of positive and negative items are utilized, unless patients are very frail cognitively. In that case, mostly positive items are used (Cohen & Mount, 1992). Kolcaba usually uses three measurement points, the first being baseline measures of the selected outcome(s). Power analysis is computed using a medium effect size, 0.80 power, and alpha of 0.10 for most interventions or protocols where known side effects are nonexistent, such as guided imagery (GI) or music therapy. The preferred test statistic is repeated measures multivariate analysis of variance (RM-MANOVA) (or if using a covariate, MANCOVA). These are appropriate statistics for

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comfort research because they capture holistically the interaction between time and intervention(s) (group assignment) and they have strong power (less subjects needed). Accounting for the impact of the interaction between time and intervention(s) (in other words, do any of the interventions increase comfort over time?) is congruent with CT. Although comfort is not a stable state from one moment to another, a trend for increased comfort over time can be demonstrated given effective comfort interventions.

All or parts of CT can be tested for research. The first part of the theory, Propositions 1 to 4, is the most frequently tested portion to date. An example of a test of these propositions was research on a new patient- controlled heated gown, requested by the manufacturer (Wagner, Byrne, & Kolcaba, 2006). The gown was designed to be used pre- and postoperatively to enhance patients' comfort, satisfaction with care, and reduce anxiety. The manufacturer consulted with Kolcaba and perioperative nurses to adapt the Thermal Comfort Questionnaire (TCQ) from the General Comfort Questionnaire (GCQ). The GCQ is registered at the National Quality Measures Clearing House (NQMC). Findings of the study, which supported the manufacturer's claims, were published in a preeminent nursing journal for operating room nurses (Wanger et al., 2006).

The second part of the theory is represented by Propositions 5 and 6, relating comfort to selected HSBs. This part provides rationale for why nurses and other health care providers should focus on patient, family, and/or nurse comfort, beyond altruistic reasons. Because HSBs include internal and external behaviors, almost any health-related outcome that is deemed important by the patient or family in a given research setting can be classified as an HSB. The task for the investigator is to justify the choice of HSBs and discuss reasons that recipients would want to engage in those HSBs, whether consciously or unconsciously. Kolcaba et al. tested Propositions 5 and 6 in their studies with persons who have urinary incontinence (UI) (Dowd, Kolcaba, & Steiner, 2000, 2002, 2003). They found that people with higher comfort were more likely to engage in HSBs and be successful in increasing bladder function and management of UI. That is, comfort was a good predictor of the extent of engagement in HSBs.

The third part of CT is represented by Propositions 7 and 8, relating patients' comfort and their engagement in HSBs to InI. The concept of InI was added to the theory in order to provide direction for outcomes research

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that would support the disciplines of nursing and other health professions. In addition, because institutions are driven by market competition to produce high patient satisfaction scores, those same institutions will be interested to know that patient and/or nurse comfort are strong predictors of patient satisfaction as well as other positive outcomes such as shorter lengths of stay, fewer hospital readmissions, and lower turnover of health care employees, especially nurses. Achieving sought-after national recognitions is another measure of InI. The practice example in Using Middle Range Theory in Practice 13.1 represents this type of comfort research.

The research examples in Using Middle Range Theories in Research 13.2 and 13.3 show how all two or three parts of CT were tested simultaneously. Effects of hand massage on patient comfort (immediate outcome) and satisfaction with care (institutional outcome) were measured in a population of long-term nursing home residents (Kolcaba, Schirm, & Steniner, 2006). In a two-group design, those who received hand massage by their nursing assistants (NAs) as a part of their hygienic care were compared to residents who received usual care (no hand massage). The intervention was incorporated easily into the (NAs) routine, but lack of administrative encouragement led to a decrease in interest in the study and performance of the intervention. Therefore, unlike other comfort studies, a trend toward gradually increasing comfort in a linear direction was not demonstrated. A systematic program of recognition of the NAs' work and contribution to science by the administrators might have resulted in positive findings.

USING MIDDLE RANGE THEORY IN RESEARCH 13.2

Source: Kolcaba, K., & Fox, C. (1999). The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncology Nursing Forum, 26(1), 67–72.

Research Purpose The study was designed to answer the question: Will women who

receive guided imagery (GI) while going through radiation therapy (RT) for early-stage breast cancer have greater comfort over time compared

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to a usual care group? (see Fig. 12.2). This question addressed Part 1 of Comfort Theory.

Research Design The study was a randomized control trial (RCT).

Sample/Participants There were 53 women (26 in the experimental group, 27 in the

control group) aged 37 to 81.

Data Collection The audiotape developed for the study facilitated the delivery of the

same holistic message every day to all women in the treatment group. In the script for GI, positive statements were directed to every cell in the TS of comfort known to be important for this population. Input for construction of the audiotape and design of the study was received from the RT nurses, technicians, and physicians.

The instruments used in this study were the Radiation Therapy Comfort Questionnaire (RTCQ), adapted from the GCQ, and four visual analog scales (one each for total comfort, relief, ease, and transcendence). During the pilot test for the methods, the women were asked specifically if there was anything left out of the questionnaire, anything that was forgotten or awkward in the audiotape, and if the instruments were easy to use. When everyone was satisfied with the protocol, the study began.

Nurses told the women who met the inclusion criteria about the study during their first appointment in the RT department. When the patients first heard about the study, about half the women burst into tears; the other half wanted to enroll. The nurses faxed to the data collectors the names and phone numbers of those who wanted to enroll, and the intake visit took place prior to the women's simulation visit. The women in the treatment group were asked to listen to the tape every day, in their own homes, with tape players that the study provided. They indicated in journals and during interviews that they complied with this request diligently for the first 3 weeks of RT, after which some were tired of the audiotape. When this occurred, they were encouraged to continue listening to the music side of the tape that would reinforce recall of the GI script. In this way, the script could be internalized.

Three complete data sets were collected (three visits for each

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woman) on 53 women, which took 1 year after IRB approvals were obtained. RM-MANOVA was used to test the hypotheses. Alpha was set at 0.10 because the intervention had no risks and the higher alpha reduced type II error (Lipsey, 1990).

Findings Analysis of group differences at baseline on demographic data and

comfort revealed that the groups were similar for all baseline variables. This was the desired result for Time 1 data. The result of the MANOVA, which analyzed data from all three time points simultaneously, was that the groups were significantly different on comfort at Times 2 and 3 (p = 0.07), a second desired result. Then, two posttests were conducted. The first was to determine which group had higher comfort (the treatment group did) and the second was to perform a trend analysis, looking at the “slopes” of the comfort data for both groups. This analysis revealed a linear slope over time, meaning that differences between the groups increased steadily over time. All of these results confirmed the efficacy of GI and supported the theory of comfort.

USING MIDDLE RANGE THEORY IN RESEARCH 13.3

Source: Dowd, T., Kolcaba, K., & Steiner, R. (2000). Using cognitive strategies to enhance bladder control and comfort. Holistic Nursing, 14(2), 91–103.

Research Purpose The purpose of this study was to test the effectiveness of audiotaped

cognitive strategies for improving comfort with innovative bladder management strategies and the HSB of actual bladder function, operationalized by incontinence and/or frequency. The research question was: Will the group practicing cognitive strategies have higher comfort and better bladder function compared to the usual care group over time?

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Research Design The study was a randomized control trial (RCT).

Sample/Participants The sample was composed of 31 adults, ages 42 to 91, with

incontinence and/or urinary frequency for at least 6 months, excluding symptoms related to urinary tract infections. Participants were randomly assigned to treatment group (n = 21) or control group (n = 19).

Data Collection A substructed diagram similar to the RT diagram was used to

organize the study. Following this diagram, the known comfort needs of this population were targeted with cognitive strategies recorded on a new audiotape. The TS was used as a guide to cover the domain of comfort with the recorded statements. Possible covariates (intervening variables) were age, gender, and particulars of bladder health history. To measure comfort in this population, the UIFCQ was adapted from the GCQ and was pilot tested before using it in this study. The HSB was improved bladder function operationalized by the Bladder Function Questionnaire (researcher developed).

Both groups received basic information about bladder function and behavioral techniques to improve bladder health. In addition, the treatment group was provided with a tape recorder and audiotape of cognitive strategies to manage symptoms and was instructed to listen to the tape once a day at their convenience for 6 weeks. Persons in the control group were provided with a tape recorder and the audiotape and instructed to listen for a period of 3 weeks.

Findings Results indicated that the treatment group had more comfort and

improved bladder function over time compared with the usual care group. In addition, a crossover component was added when those in the original comparison group listened to the audiotape for 3 weeks, after which data were collected again from both groups. A significant improvement on bladder function was found in the crossover group, and their comfort had increased to the level of the treatment group after 3 weeks of the intervention.

Another interesting finding was that the UIFCQ predicted which

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participants (N = 17, or 90% of the treatment group) would demonstrate improvement in incontinence. Because comfort was a strong predictor of benefit from treatment for incontinence and frequency, these findings also supported the strengthening component of the theory of comfort.

In a three-group design, a modified GCQ was utilized to measure differences in comfort and stress between groups of college students, ages 18 to 24, randomly assigned to healing touch (HT), coaching, or a combined intervention of HT and coaching. Repeated measures revealed that HT had better immediate results on both outcomes, while coaching had better carryover effects. Findings for the combined treatment group were inconsistent, probably due to methodological issues (Dowd, Kolcaba, Steiner, & Fashinpaur, 2007).

The TS of comfort was utilized to create a Portuguese instrument for hospitalized psychiatric patients to test the effectiveness of GI for increasing comfort (immediate outcome) and decreasing depression, anxiety, and stress (subsequent outcomes). Repeated measures revealed that the treatment group had significantly improved comfort and decreased depression, anxiety, and stress over time (Apostolo & Kolcaba, 2009).

For health care research, patient comfort can be correlated with institutional factors such as nurse–patient ratios, levels of nursing education, new hospital policies or protocols, strategies for nurse retention, and/or specific nursing interventions (especially those considered to be holistic or adjunctive to medical strategies). A full taxonomy of comfort measures is now available in the electronic NANDA data base as nursing diagnoses, interventions, and outcome measures. The patient outcome of comfort can be added to other electronic data bases or paper records as well. Identifying and tracking value-added nursing outcomes by staff nurses on their units and nursing leaders for the entire division, agency, or hospital is important for (a) earning recognition for one's sphere of influence, (b) elevating the specific contribution of nursing to health care of patients, and (c) counteracting the negative and dangerous reputations that have been created regarding hospital stays.

In addition, in a pay-for-performance (futuristic) reimbursement environment, comfort is a value-added and nursing-sensitive outcome; that is, when patients and their families experience increased comfort, a benefit that they desire and need, through the direct actions and behaviors of a nurse, those actions and behaviors could be reimbursed separately. The

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credibility and validity of the GCQ and its modifications is ideally suited for this purpose. In 2003, the complete instrument was registered as a multidisciplinary outcome indicator by the National Quality Measures Clearinghouse (NQMC). This type of positive (value-added) patient/family measure is unusual because it is a direct indicator of quality, rather than an indirect indicator. Indirect indicators are actually indicators of poor quality such as “death among surgical patients,” “prevalence of pressure ulcers,” and “incidence of inpatient falls with injuries” as listed in the current version of the National Quality Forum nursing-related outcome indicators (Dunton, Gonnerman, Montalvo, & Schumann, 2011).

Instruments Used in Empirical Testing

General Comfort Questionnaire If you want to do a comfort study yourself, and a comfort instrument needs to be constructed for your unique population, you can start with the GCQ and adapt it using your knowledge of the population. Detailed instructions for doing so are on the web (Kolcaba, 1997) and a full discussion of how the GCQ was developed is in Kolcaba (1992) and Kolcaba (2003).

As with the other comfort questionnaires available, the GCQ began with the TS. The GCQ contains two positive and two negative items for each of the 12 cells in the TS, resulting in 48 items. A four-response Likert-type scale was used for the pilot test, although subsequent questionnaires have six responses, which increase sensitivity of the instrument. An even number of responses also forces the responder to choose one side of the comfort fence or the other.

The GCQ was pilot tested in the community (N = 30) and several types of hospital units (N = 226). Results of this first instrumentation study were encouraging, as the Cronbach's alpha was 0.88, very high for a new instrument. (Perhaps, working from a theoretically driven map of the content domain helped!) Factor analysis, using principal components analysis, extracted 13 factors with eigenvalues above 1.0. The 13th factor had only one item and was collapsed into one of the other factors that was

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semantically similar, producing 12 factors consistent with the TS. In addition, factors were grouped together in three subscales on the screen plot that were semantically similar to the types of comfort (relief, ease, and transcendence). This factor structure accounted for 63.4% of the variance in the 48 items (Kolcaba, 1992).

Reliabilities for the subscales (factors) ranged from 0.66 to 0.80, which were lower than for the whole GCQ (0.88). This is because lower numbers of items generally decrease reliability scores. The GCQ revealed significant sensitivity in expected directions between several groups (construct validity). Findings were that (a) the community group had higher comfort than the hospital group and (b) people with higher comfort demonstrated a higher correlation with their own estimates of progress in rehabilitation.

When researchers adapt the GCQ to fit their population, they can use the psychometric properties and description of the instrumentation study (above) to support their choice of a comfort instrument. If appropriate, the number of items can be shortened or whole subscales that are not relevant can be removed. However, with each of those strategies, reliability scores may decrease. It is important, therefore, to pilot test adapted instruments with at least 15 subjects who are characteristic of those in the proposed study. A Cronbach's alpha of at least 0.70 is desirable for a new instrument. Kolcaba appreciates submission of your new instruments to her Web site (Kolcaba, 1997), so future researchers do not have to “reinvent the wheel” and the preliminary psychometric statistics that support use of comfort instruments.

The credibility and validity of the GCQ and its modifications are ideally suited for this purpose. In 2003, the complete instrument was registered as a multidisciplinary outcome indicator by the National Quality Measures Clearinghouse (NQMC, 2002). This type of positive (value- added) patient/family measure is unusual because it is a direct indicator of quality, rather than an indirect indicator. Indirect indicators are actually indicators of poor quality such as “death among surgical patients,” “prevalence of pressure ulcers,” and “incidence of inpatient falls with injuries” as listed in the current version of the National Quality Forum nursing-related outcome indicators (Dunton et al., 2011). In addition, in a pay-for-performance (futuristic?) reimbursement environment, comfort is a value-added and nursing-sensitive outcome; that is, when patients and their families experience increased comfort, a benefit that they desire and need, through the direct actions and behaviors of a nurse, those actions and

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behaviors could be reimbursed separately.

Verbal Rating Scales For clinical research, patient comfort can be assessed with verbal ratings similar to those now conducted for pain. When a patient is asked to rate his/her comfort from 0 to 10, meaningful conversations can be initiated about detractors from comfort in the clinical setting and possible solutions. Findings from the use of verbal rating of either total comfort or discomfort can easily be added to documentation forms in health care settings. In a test of their reliability, verbal ratings of total comfort provided statistically significant data when comparing the effects of two comfort interventions, coaching and HT, for the goal of increasing comfort and decreasing stress of college students (Dowd et al., 2007).

Verbal ratings can be correlated with institutional factors such as nurse–patient ratios, levels of nursing education, new hospital policies or protocols, strategies for nurse retention, and specific nursing interventions (especially those considered to be holistic or adjunctive to medical strategies). A full taxonomy of comfort measures is now available in the electronic NANDA data base as nursing diagnoses, interventions, and outcome measures. Identifying and tracking value-added nursing outcomes by nursing leaders is important for (a) earning recognition for ones unit, agency, or hospital, (b) elevating the contribution of nursing to health care in general, and (c) counteracting the negative and dangerous reputations that have been created regarding hospital stays.

Radiation Therapy Comfort Questionnaire To adapt the GCQ to women with breast cancer, items that were not relevant for RT were deleted. The literature identified critical comfort needs specific to this population. From this list of needs, positive and negative items were developed to complete and balance the questionnaire for this population.

A consideration when developing the Radiation Therapy Comfort Questionnaire (RTCQ) was the length of time it would take for the women

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to answer it. The nurses thought, and it was later confirmed, that many research participants would choose to complete the questionnaires in the RT department rather than in their homes. In addition, the design of the study was to administer all questionnaires immediately prior to RT. A 48- item questionnaire was deemed too long by the RT staff and probably too stressful for the women. So, for this study, a 26-item RTCQ was pilot tested. The instrument performed fairly well in the final study with a Cronbach's alpha of 0.76 (N = 53, 26 items).

Urinary Incontinence and Frequency Comfort Questionnaire For the comfort study with persons with UI, the Urinary Incontinence and Frequency Comfort Questionnaire (UIFCQ) was adapted from the GCQ and contained 23 positive and negative items specific to the experience of living with UI. A six-response Likert-type format, ranging from strongly agree to strongly disagree, was used. After reverse coding negative items, higher scores indicated higher comfort. In this study, 31 women and 9 men participated. The Cronbach's alpha averaged 0.82 across the four measurement points indicating good reliability. The instrument was sensitive to changes in comfort over time (p = 0.01) (Dowd et al., 2000).

Hospice Comfort Questionnaire (Family and Patient) For this population, the GCQ was adapted again to create a 49-item Hospice Comfort Questionnaire (HCQ). Family members were asked to rate their own comfort, not that of their patient. The adapted instruments were tested in two phases (Novak, Kolcaba, Steiner, & Dowd, 2001). In phase I, patient and FM questionnaires had a six-item Likert scale response set, ranging from “strongly agree” to “strongly disagree,” and higher scores indicated higher comfort. Each questionnaire took about 12 minutes for patients to complete and usually less time for FMs. Approximately equal numbers of positive and negative items were created for the FMs' EOL questionnaire; items were worded more simply and with less alternating between positive and negative orientations. This adaptation was

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necessary because of decreased mental agility in dying patients (Cohen & Mount, 1992).

In phase II, patient and caregiver questionnaires were reduced to a four-item Likert response set, because of concerns of the data collectors that six responses were too confusing. However, results showed that the instrument in phase I (six responses) had the strongest psychometric properties for both FMs and patients. Cronbach's alpha for the FM questionnaire was 0.89 (N = 38) and for the patient questionnaire was 0.83 (N = 48) (Novak et al., 2001).

In spite of these high reliability scores, nurse researchers working with this population a few years later thought that 49 items were too many, and they asked a panel of experts to prioritize the items that were most important. From that list of priority items, 24 of the highest items were plotted on the TS and balanced over the content domain. The result is a 24- item HCQ. This instrument was used in an experiment with hospice patients in which a hand massage protocol was tested with 31 patients over a 3-week period. Despite a lenient alpha of 0.10, the study did not yield significant results overall. However, of clinical significance is that comfort increased somewhat in the treatment group even as patients approached death, while, in the usual care group, comfort scores decreased steadily over the three weekly measurement points (Kolcaba, Dowd, Steiner, & Mitzel, 2004).

Healing Touch Comfort Questionnaire The Healing Touch Comfort Questionnaire (HTCQ) was adapted from the GCQ following the same procedure described previously. Three experts reviewed it for appropriateness of wording and content, eight HT practitioners distributed the questionnaire to their clients, and 53 persons completed them within several days of the treatment. The questionnaires were returned in self-addressed envelopes provided by the research team. Cronbach's alpha for the HTCQ was 0.94 for total comfort. Those who had received 5 or more HT treatments had comfort scores of 13.7 points higher than those who had received 1 to 4 treatments. Further analysis showed that there was a trend to a curvilinear relationship between number of treatments and comfort. Comfort seems to increase slightly as the number of treatments increases until about 20 treatments; then comfort levels off and possibly declines. More information is needed about this relationship

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(Dowd et al., 2006). The HTCQ was utilized in the study with college students described

earlier (Dowd et al., 2007) to establish reliability of the findings from the verbals. Cronbach's alpha in this study revealed an average of 0.93 over three measurement points. The HTCQ was highly and positively correlated with verbal ratings for comfort.

Comfort Behaviors Checklist Research with patients near end of life and their family members is in its infancy. Comfort is consistently stated as a desired outcome in hospice standards of care, which makes CT particularly cogent for research with patients near end of life. Making it even more applicable for hospice or palliative research is Schlotfeldt's (1975) inclusion of peaceful death as an HSB, another subsequent outcome. Sometimes, a peaceful death is the most realistic outcome in a particular situation, and Schlotfeldt's elevating peaceful death to an HSB was an example of how her thinking was “ahead of her time.” However, data collection with patients near end of life is fraught with difficulties. For these reasons, Kolcaba (1997) developed a Comfort Behaviors Checklist (CBC), which data collectors can use to rate a patient's apparent comfort if the patient loses the cognitive ability to rate his or her own comfort. While not as desirable as actually asking a patient about his or her comfort, the instrument fills a gap regarding data collection in very frail or cognitively limited patients. This CBC was recently adapted for clinical documentation of babies' apparent comfort by pediatric nurses from a large Western health care system (Kolcaba, 1997).

Other patients whose comfort could be indirectly assessed by nurses are those who are mentally disabled, brain injured, heavily sedated, or unconscious. Using the CBC, a nurse or data collector rates the patient's comfort based on observable behaviors. It contains 29 observations with possible responses of not applicable, no, somewhat, moderate, and strong (Kolcaba, 1997). The instrument includes positive indicators of comfort in addition to signs that indicate a lack of comfort. Directions for scoring of the CBC are on Kolcaba's Web site, where she directs researchers how to calculate results as a percentage instead of adding total points.

Interrater comparisons were performed with long-term care residents to test the reliability of the instrument. A deviation of 20% points between raters for each subject was considered clinically and empirically

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unreliable. Conversely, a deviation between raters of 10% points for each subject was considered to be acceptable, and a deviation of 5% points was a demonstration of very strong interrater consistency. Distributions of the differences in ratings in 39 data sets were as follows: (a) 36 data sets revealed a 10-point difference or less between raters 1 and 2 for each subject (p = 0.92; alpha 0.95), and (b) 31 data sets revealed a 5-point difference or less between raters 1 and 2 for each subject (p = 0.80; alpha 0.95). These findings indicated strong interrater consistency. These findings were repeated with a version of the CBC modified for pediatric surgical patients.

However, when scores from the CBC were correlated with residents' responses on the traditional GCQ, low correlations were revealed, averaging a Cronbach's alpha of 0.14 over three distinct time points. These disappointing findings seemed to indicate that the interior life or feelings of human beings cannot be fully appreciated until they are asked. The stoic demeanors of the long-term care residents, which appeared to indicate comfort, masked many complex feelings about their own comfort. However, in the absence of the ability to verbalize or indicate specific feelings about comfort, the CBC is, perhaps, better than no comfort assessment at all and can serve to indicate increases in percentage points associated with comfort interventions or protocols.

All of these instruments, and others under development or in different languages, are available on Kolcaba's Web site (Kolcaba, 1997).

Summary The theory of comfort provides a framework for research in any setting where patients have comfort needs and enhancing their comfort is valued. The theory has been used to test the effectiveness of specific holistic interventions for increasing comfort, to demonstrate the correlation between comfort and subsequent HSBs, and to relate HSBs to desirable institutional outcomes. It is important as a framework for interdisciplinary care and research because the focus is on the unifying and positive outcome of patient comfort. As such, CT has been used in many health care specialties, both nationally and internationally.

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As a value-added indicator of improved quality, the desired outcome of comfort is used by nursing leaders for practice and research.

Critical Thinking Exercises

1. Nurse leaders attempt to advance practice one unit or agency at a time. In order to bring a philosophy of comfort management to your practice setting, rationale must be developed and presented. Compile logical and compelling rationale for implementing comfort management at your site and a brief proposal for how you would implement this model.

2. In order to practice comfort management, evidence must be collected about patients'/families' comfort needs, comfort interventions to address those needs, and assessment of baseline comfort compared to comfort after the intervention(s). Design appropriate comfort management documentation for your unit.

3. Research evidence suggests that patients do better when their expectations about specific benefits of nursing care are discussed and met. Design a “comfort contract” whereby patients or their surrogates designate an expected level of postsurgical overall comfort and also where they can specify chronic discomforts and interventions that they use at home for relief.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Comfort Care.

REFERENCES Apostolo, J., & Kolcaba, K. (2009). The effects of guided imagery on

comfort, depression, anxiety, and stress of psychiatric in patients with depressive disorders. Archives of Psychiatric Nursing, 23(6), 403–411.

Cohen, S., & Mount, B. (1992). Quality of life in terminal illness: Defining and measuring subjective well-being in the dying. Journal of Palliative Care, 8(3), 40–45.

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http://thePoint.lww.com/Peterson4e

Dowd, T., Kolcaba, K., & Steiner, R. (2000). Using cognitive strategies to enhance bladder control and comfort. Holistic Nursing Practice, 14(2), 91–103.

Dowd, T., Kolcaba, K., & Steiner, R. (2002). Correlations among six measures of bladder function. Journal of Nursing Measurement, 10(1), 27–38.

Dowd, T., Kolcaba, K., & Steiner, R. (2003). The addition of coaching to cognitive strategies. Journal of Ostomy and Wound Management, 30(2), 90–99.

Dowd, T., Kolcaba, K., & Steiner, R. (2006). Development of an instrument to measure holistic client comfort as an outcome of healing touch. Holistic Nursing Practice, 20(3), 122–129.

Dowd, T., Kolcaba, K., Steiner, R., & Fashinpaur, D. (2007). Comparison of a healing touch, coaching, and a combined intervention on comfort and stress in younger college students. Holistic Nursing Practice, 21(4), 194–202.

Dunton, N., Gonnerman, D., Montalvo, I., & Schumann, M. (2011). Incorporating nursing quality indicators in public reporting and value- based purchasing initiatives. American Nurse Today, 6(1), 14–17.

Glaser, C., & Strauss, A. (1965). Awareness of dying. Chicago, IL: Aldine. Goodwin M., Sener, I., & Steiner, S. (2007). A novel theory for nursing

education: Holistic comfort. Journal of Holistic Nursing, 25(4), 278–285.

Henderson, V. (1978). Principals and practice of nursing. New York, NY: Macmillan.

Kolcaba, K. (1991). A taxonomic structure for the concept comfort. Journal of Nursing Scholarship, 23(4), 237–239.

Kolcaba, K. (1992). Holistic comfort: Operationalizing the construct as a nurse-sensitive outcome. Advances in Nursing Science, 15(1), 1–10.

Kolcaba, K. (1994). A theory of holistic comfort for nursing. Journal of Advanced Nursing, 19, 1178–1184.

Kolcaba, K. (1997). The comfort line. Retrieved October 7, 2011, from http://www.thecomfortline.com

Kolcaba, K. (2001). Evolution of the mid range theory of comfort for outcomes research. Nursing Outlook, 49(2), 86–92.

Kolcaba, K. (2003). Comfort theory and practice: A vision for holistic health care and research. New York, NY: Springer.

Kolcaba, K., Dowd, T., Steiner, R., & Mitzel, A. (2004). Efficacy of hand massage for enhancing comfort of Hospice patients. Journal of Hospice and Palliative Care, 6(2), 91–101.

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http://www.thecomfortline.com

Kolcaba, K., & Fox, C. (1999). The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncology Nursing Forum, 26(1), 67–72.

Kolcaba, K., & Kolcaba, R. (1991). An analysis of the concept of comfort. Journal of Advanced Nursing, 16, 1301–1310.

Kolcaba, K., Schirm, V., & Steiner R. (2006a). Effects of hand massage on comfort of nursing home residents. Geriatric Nursing, 27(2), 85–91.

Kolcaba, K., Tilton, C., & Drouin, C. (2006b). Use of comfort theory to enhance the practice environment. Journal of Nursing Administration, 36(11), 538–544.

Lipsey, M. (1990). Design sensitivity. New Park, CA: Sage. March, A., & McCormack, D. (2009). Nursing theory-directed healthcare.

Holistic Nursing Practice, 23(2), 75–80. McIlveen, K., & Morse, J. (1995). The role of comfort in nursing care:

1900–1980. Clinical Nursing Research, 4(2), 127–148. Nightingale, F. (1859). Notes on nursing. London, UK: Harrison. Novak, B., Kolcaba, K., Steiner, R., & Dowd, T. (2001). Measuring

comfort in caregivers and patients during late end-of-life care. American Journal of Hospice and Palliative Care, 18(3), 170–180.

NQMC. (2002). National Quality Measures Clearinghouse. Accessed January 18, 2011, from http://qualitymeasures.ahrq.gov/comfort

Orlando, I. (1961/1990). The dynamic nurse–patient relationship. New York, NY: National League for Nursing.

Paterson, J., & Zderad, L. (1976/1988). Humanistic nursing. New York, NY: National League for Nursing.

Schlotfeldt, R. (1975). The need for a conceptual framework. In P. Verhonic (Ed.), Nursing research (pp. 3–25). Boston, MA: Little & Brown.

Wagner, D., Byrne, M., & Kolcaba, K. (2006). Effect of comfort warming on preoperative patients. AORN Journal, 84(3), 1–13.

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14 Health-Related Quality of Life

Kristin E. Sandau, Timothy S. Bredow, and Sandra J. Peterson

Definition of Key Terms

Health-related quality of life (HRQOL) Subset of quality of life representing satisfaction in areas of life likely to be affected by health status; HRQOL is subjective, multidimensional, and temporal.

Life domains Basic components of quality of life and HRQOL referring to specific aspects of life, most commonly physical, cognitive, socioeconomic, and psychological/spiritual.

Nursing interventions Although rarely included as a component in formal theoretical models of HRQOL, involve delivering specific care or treatments targeted for an individual or group who have deficits or potential deficits in an identified domain that may impact HRQOL.

Quality of life Satisfaction in areas of life deemed important to the individual.

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Introduction Quality of life (QOL) has been a philosophical and sociopolitical phenomenon for hundreds, if not thousands, of years. Because QOL is not clearly identified with one theorist, it is difficult to define and describe. This lack of specificity has not diminished its popularity as an outcome measure among patients tested in thousands of studies published both nationally and internationally. QOL has been identified as a middle range theory (Meleis, 1997) representing a specific phenomenon, with a limited number of related concepts, that has obvious applications to practice. The more limited construct of health-related QOL in the context of health care (often referred to as HRQOL) may be even more fitted as a middle range theory because HRQOL is somewhat more limited in focus on areas of life most directly influenced by one's health.

Historical Background The concept of QOL, concerned with an individual's personal satisfaction with life, has its roots in classical Greek thought and religious teachings. Aristotle is credited with the initial conceptualization of QOL, defined as happiness, the good life, or the outcome of a life of virtue (Morgan, 1992). In the New Testament (John 10:10), Jesus stated that he came to give life and give it abundantly (Crosway, 2011). The 10 stages of enlightenment in Buddhism start out with achieving joy in life (Stryk, 1968).

Pigou has been credited with modern introduction of the term in 1920 in his book on economics and welfare (Wood-Dauphinee, 1999). Politically, use of the concept, QOL, was limited until it was reintroduced in remarks made by Presidents Johnson and Nixon in speeches on environmental and social issues (Campbell, 1981; Dalkey, Rourke, Lewis, & Snyder, 1972). QOL has its academic roots in the disciplines of psychology and sociology (Spranger, 2001). In the 1970s, these disciplines began to consider the issue of QOL. In the 1970s, the business world adopted the term QOL to make claims about the ability of a product to enhance a person's life in the milieu of everyday living.

The WHO's more encompassing definition of health as physical, psychological, and social well-being, and not just the absence of illness or

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infirmity (World Health Organization, 1948), provided early impetus to the consideration of QOL as a relevant human experience for health care professionals. In 1978, the WHO provided a statement on the application of its definition of health, indicating that individuals have the right “to psychosocial care and adequate QOL in addition to physiologic care” (King & Hinds, 1998, p. xi). Nursing's interest in QOL is long standing. Florence Nightingale's involvement with the British military provided multiple examples of how nurses can promote the QOL for individuals. This interest has intensified and become a focus of research for nurses.

HRQOL, a subcategory of global QOL, is a more recent concept. Health care trends have contributed to the emergence of HRQOL as an important phenomenon. In the past 15 to 20 years, the concern for patients has become more inclusive, focusing not just on the treatment of disease but also on the restoration and promotion of health (Read, 1993). With increased client longevity, health care professionals are attending to the lifestyle issues that accompany chronic disease and often affect QOL. The Food and Drug Administration (FDA) is reflecting this changing emphasis. It can require documentation of not only the safety and efficacy of new products but also their effect on a user's QOL (Spilker, 1996).

QOL has emerged as a concept of interest to many disciplines. This multiplicity of discipline-specific perspectives has led to little consensus on a definition. Philosophers consider the nature of existence and what is meant by the “good life.” Ethicists are concerned with social utility. Economists pursue cost-effectiveness in producing the greatest good. Physicians focus on health- and illness-specific issues, while nurses may approach the issue of QOL more holistically (Anderson & Burckhardt, 1999).

Definition of Theory Concepts QOL and the subconstruct HRQOL have suffered from a lack of clarity for both conceptual and operational definitions in research studies. Regrettably, some researchers published results of HRQOL outcome studies without first stating their conceptual definition of HRQOL. Similarly, several researchers have not accurately matched their conceptual definition with their operational definition. For example, researchers have inaccurately stated that they are measuring the broad

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construct of QOL but have instead operationalized QOL as an objective measure, such as length of time without return to surgery (Elkins, Knott- Craig, McCue, & Lane, 1997).

In the 1980s and early 1990s, many researchers reported outcomes as QOL or HRQOL but had only measured one domain, such as physical functional status. However, functional status is not interchangeable with the construct HRQOL and is most appropriately considered only one of several components contributing to overall HRQOL. Functional status has traditionally been defined by degree of disability to perform standard activities in life (Stineman, Lollar, & Ustun, 2005). QOL is an even broader construct than is HRQOL: inclusive of all life domains important to a person. The construct HRQOL developed as an entity separate from global QOL as a means of specifying health-related domains of particular interest to researchers (Wenger, Naughton, & Furberg, 1996).

Some authors have used the term subjective health status interchangeably with HRQOL, considering it a more accurate descriptor of the phenomenon (Staniszewska, 1998). However, Ferrans, Zerwic, Wilbur, and Larson (2005) categorized approaches to HRQOL measurement as perceived status or evaluative approaches to HRQOL. HRQOL-perceived status measures ask patients to rate their functional abilities, such as the commonly used SF-36 survey (Ware & Sherbourne, 1992) and the EORTC Quality of Life Questionnaire (Aaronson et al., 1993). Alternatively, HRQOL evaluation measures, such as the Ferrans and Power Quality of Life Index (Ferrans, 1990a) and the Quality of Life Scale for Cancer (Padilla et al., 1983), place less emphasis on the specific functional abilities and more emphasis on the patient's perception of how satisfied he or she is with his or her abilities or life domains. Both perceived status and evaluation measures have a purpose in research. Perceived status may be helpful in testing specific effects of an intervention, while evaluation measures may capture more personal judgments of life satisfaction based on internal expectations that are changeable within the individual. Some measures incorporate both perceived status and evaluative approaches. Such is the case with the WHO Quality of Life Assessment, which covers physical, psychological, social, and spiritual domains, and as a result is quite lengthy (World Health Organization, 1995). The McGill Quality of Life Questionnaire uses evaluation approaches for its four domains, with additional status approaches for two of these domains (Cohen, Mount, Strobel, & Bui, 1995).

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Despite significant confusion over related terminology, theorists and researchers have increasingly described the constructs of QOL and HRQOL as having three characteristics: HRQOL is multidimensional, temporal, and subjective. The multidimensional aspect of HRQOL (Aaronson et al., 1993; Faden & Leplege, 1992; Staniszewska, 1998) is reflected by the major life domains, commonly identified as physiological, psychological, and sociological (Padilla & Grant, 1985). Other investigators have stated that a spiritual domain is of importance (Cella & Tulsky, 1990; Ferrans & Powers, 1985). Recent publications have featured physical, psychosocial, spiritual, emotional, and cognitive/mental dimensions. Osoba (1994) has suggested that researchers can appropriately refer to their study as measuring HRQOL if at least three life domains received assessment.

HRQOL is temporal in nature; patients can change their self- perceptions as they experience events in everyday life and process what they feel are QOL priorities (Peplau, 1994; Sprangers & Schwartz, 1999). Some scholars state that HRQOL is primarily subjective in nature but may include objective assessments at times (Oleson, 1990; Zhan, 1991). However, most researchers now consider HRQOL as subjective in nature (Cella, 1992; Cooley, 1998; Harrison, Juniper, & Mitchell-DiCenso, 1996; Murdaugh, 1997). Further investigation is needed for practical considerations related to ethical implications of allowing those other than the patients to make treatment decisions based on assumed HRQOL when the patients are unable to speak for themselves, such as those in vegetative states. Work has been done to test the validity of parallel administration of subjective HRQOL with proxy health status measures completed for patients by health care providers or family members (Addington-Hall & Kalra, 2001). Measures obtained by others would be most accurately referred to as proxy subjective health status rather than HRQOL.

Description of the Theory of Quality of Life and Health-Related Quality of Life There are many models of QOL or HRQOL (Cowan, Graham, &

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Cochrane, 1992; Ferrell, Grant, Dean, Funk, & Ly, 1996; Ferrans, 1990b; Oleson, 1990; Padilla & Grant, 1985; Zhan, 1992, as found in King & Hinds, 1998), most of which omit the relationship between specific interventions and the factors that affect HRQOL. Three seminal models of QOL were provided in the 1990s. Spilker (1996) provided an introductory framework for QOL in health care by illustrating QOL as a pyramid of three levels (Fig. 14.1). A model by Ferrans and Powers (1993) also identified QOL as a main outcomes measure, rather than HRQOL (Fig. 14.2). However, HRQOL researchers have sometimes chosen to concentrate on specific parts of the model rather than the entire model. Researchers have adapted models for use according to the specific condition or population they wish to study (Sandau, Lindquist, Treat- Jacobson, & Savik, 2008). While technically a model may be designed to illustrate QOL, clinicians wishing to research the more limited construct of HRQOL have made adaptations. Researchers should provide clarity about how any adapted or abbreviated conceptual definition supports their selected operational measures.

Figure 14.1 Three levels of quality of life. (From Spilker, B. (Ed.). (1996). Quality of life and pharmacoeconomics in clinical trials (2nd ed., p. 2). Philadelphia, PA: Lippincott-Raven Publishers.)

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Figure 14.2 Quality-of-life framework. (From Ferrans, C. E. (1990). Quality of life: Conceptual issues. Seminars in Oncology Nursing, 6(4), 248–254.)

Nurses Ferrans and Powers developed a theory in which they provided the seminal definition of QOL as a person's “sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her” (Ferrans & Powers, 1992, p. 29). Because their model encompassed all major life domains, their resulting operational measure, the Ferrans & Powers QOL Index, is a global multidimensional measure designed to represent the comprehensive construct of QOL (Fig. 14.2). The listed domains are health and functioning, socioeconomic, psychological/spiritual, and family.

A commonly cited model in health care disciplines is that of Wilson and Cleary (1995). Although both authors were physicians, the model combines the “social” paradigm with the “medical” paradigm. This model represents the relationships among the basic concepts of HRQOL. The model identifies five determinants that exist on a “continuum of increasing biological, social, and psychological complexity” (p. 60). These leveled determinants of HRQOL are referred to as taxonomy and consist of biological factors, symptoms, functioning, general health perceptions, and overall HRQOL. They are in turn influenced by characteristics of the individual and environment.

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Sousa and colleagues tested the Wilson and Cleary model, using multiple linear regression path analysis to evaluate the variables for empirical linkages to overall HRQOL (Sousa, Holzemer, Henry, & Slaughter, 1999). They reported that data were consistent with the theory and reported a 32% variance in overall QOL among their sample of persons with HIV. However, biological and physiological variables provided the weakest correlations with the other variables, suggesting little influence. The authors indicated that further research was necessary into areas such as other potential influences of personality, motivation, and social and economic supports, as well as the influences of time over the model (Sousa, 1999). Sousa and Chen (2002) continued work using structural equation modeling to address conceptual issues of HRQOL. The Wilson and Cleary model encompasses several large constructs as variables, so theory testing the model in its entirety is an intensive feat and is rarely done.

Anderson and Burckhardt (1999) suggested that a major limitation of the Wilson and Cleary model is that the medical factors seem central, rather than the nonmedical factors, to the overall HRQOL. Similarly, Murdaugh (1997) contended that the Wilson and Cleary model may be more accurately referred to as a taxonomy of patient outcomes due to its continuum of intuitively linked pathways with little empirical support. The majority of variance for overall HRQOL was unexplained, and many questions remain. Further study of relationships between other variables that can be affected by independent nursing interventions affecting QOL and HRQOL (such as interventions to support resiliency, self-efficacy, and hope) is encouraged.

Wilson and Cleary have described the arrows in the figure to represent the dominant causal relationships without excluding reciprocal connections between either adjacent or nonadjacent components of the model. Ferrans and nursing colleagues offered a revision to the Wilson and Cleary model (Ferrans, Zerwic, Wilbur, & Larson, 2005), in which they made three major changes: they (a) added arrows to show that biological function is influenced by characteristics of the environment and individual, (b) deleted nonmedical factors, and (c) deleted labeling on arrows, which tends to restrict relationships.

Work by Padilla and Grant (1985) occurred as early as the above models but, aside from the oncology realm, appears to have been less recognized among health disciplines. Their work deserves discussion because it offered one of the first QOL models to specifically include

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independent nursing process interventions as a component in the formal model (Fig. 14.3). These include caring attitude, specific nursing interventions, and promotion of self-care. These interventions are perceived by the patient and influence outcome variables that can be categorized by QOL dimensions. For example, the nursing interventions to promote healthy body image in a patient with a new colostomy can influence the patient's overall QOL by contributing to enhanced or maintained body image. Extraneous variables are recognized in the model, such as the individual's prognosis and personal characteristics, and whether the colostomy is temporary or permanent.

Figure 14.3 A model of the relationship between the nursing process and the dimensions of quality of life. (From Padilla, G. V., & Grant, M. M. (1985). Quality of life as a cancer nursing outcome variable. Advances in Nursing Science, 8(1), 45–60.)

For their model, nurse researchers Stuifbergen, Seraphine, and Roberts (2000) used structural equation modeling to test the selected factors influencing health-promoting behavior or QOL in persons with chronic disabling conditions. QOL was defined as “an individual's overall sense of health, well-being, and satisfaction with life” (p. 124). A complex interaction of contextual factors (severity of illness being most dominant), antecedent variables, and health-promoting behaviors all contributed to QOL in their proposed model. Interventions to enhance mediating factors

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of social support, acceptance, decreased barriers to self-efficacy, and increased self-efficacy for health behavior can contribute to health- promoting factors and enhanced QOL. The purposeful use of concepts that are currently being tested in nursing makes this model unique to nursing and within the scope of independent nursing interventions. Additionally, Leplege and Hunt (1997) commended the authors for acknowledging the interconnectedness of QOL with other aspects of existence such as changes in work, coping strategies, personal relationships, and self-image.

Application of the Theory in Research HRQOL measurement provides an understanding of the patient-perceived outcome experience of chronic illness, evaluation of a procedure, medication, or other intervention between groups, among individuals, or between populations. More recently, HRQOL measures have been used to evaluate efforts of health promotion, including independent nursing interventions such as education and counseling (see Using Middle Range Theory in Research 14.1). Use of formal HRQOL measures has not been routine in clinical practice. The gap between research and clinical practice was fed by the initial lack of understanding that HRQOL measures are not “soft” optional measures but determinates helpful in clinical practice (Rumsfeld, 2002). Rubenstein (1996) provided a table summary of recommendations for incorporating routine and symptom-specific HRQOL screenings into office practice. McClane (2006) recommended three specific HRQOL measures for use by clinical nurse specialists in routine clinical assessment of elderly persons.

USING MIDDLE RANGE THEORIES IN RESEARCH 14.1

Source: Harrison, M. B., Browne, G. B., Roberts, J., Tugwell, P., Gafni, A., & Graham, A. D. (2002). QOL of individuals with heart failure: A randomized trial of the effectiveness of two models of hospital-to-home

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transition. Medical Care, 40(4), 271–282.

Research Purpose Harrison and colleagues conducted a randomized controlled trial to

evaluate the effect of transitional care on HRQOL, rates of readmission, and emergency room use of patients with heart failure.

Research Design A 12-week, prospective, randomized controlled trial

Sample/Participants One hundred and fifty-seven adult hospitalized patients with heart

failure.

Data Collection The nurse-led intervention included education and support for self-

management for a period of 2 weeks after hospital discharge. HRQOL was operationalized by using both a generic health status (SF-36) and disease-specific QOL measure (Minnesota Living with Heart Failure Questionnaire [MLHFQ]).

Findings At 6 weeks after hospital discharge, the overall MLHFQ score was

better among the patients randomized to receive the nurse-led intervention than among the usual care patients. However, there was no significant difference in any of the subscales for the SF-36. At 12 weeks after discharge, more of the control group had been readmitted compared to the intervention group (31% versus 23%), and significantly, more of the usual care group visited the emergency department compared with the transitional group (46% versus 29%). This study provides evidence-based support for nurse-led interventions to successfully improve HRQOL.

The article, like many published in clinical journals, lacked a conceptual definition for HRQOL. However, the authors are to be commended for attempting to address whether or not the statistically significant improvements on the MLHFQ could be considered clinically significant. The authors added a “minimally clinical importance difference” (MCID) analysis, which they defined as a 5-point or greater change in the total MLHFQ score. Relative changes in score between

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baseline and 12 weeks postdischarge were compared for both groups; the most contrast in scores was with the MLHFQ emotional dimension, where improvement was 36% for the transitional group (versus <1% for the control group). Finally, the fact that the generic SF-36 scores were not improved, while the MLHFQ scores were improved, highlights the importance of knowing one's sample and selecting a measure that will be sensitive to changes expected by a particular intervention in a select population.

Instruments Used in Empirical Testing

Categories of Measurement Measurement tools for HRQOL can be categorized in a variety of ways. For example, one category of measure is based on the number of life domains that are encompassed within the measure. If a tool is designed to examine a full spectrum of life domains, it may be considered global. Global tools are important because they may show QOL changes in all domains of life. Heart failure, for example, may have a pervasive effect on patients' ability to generate income, socialize, and be sexually intimate. The Minnesota Living with Heart Failure Questionnaire (Rector, Kubo, & Cohen, 1987) attempts to capture a global perspective of the impact of a specific disease on various domains of life. In contrast to global measures, another category is that of measures that target a single domain, such as psychological health, as is offered by the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983).

Table 14.1 provides a method of categorizing types of tools commonly used to measure QOL and HRQOL. Generic tools, while not specific to disease or treatment, are helpful for making comparisons across studies and between populations (Guyatt, Feeny, & Patrick, 1993). The Nottingham Health Profile has been commonly used in the United Kingdom as a generic tool but is also considered global because of its broad coverage of various life domains (Hunt, McEwen, & McKenna,

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1985). The SF-36, which is a generic measure of subjective health status, provides two main summary scores for self-perceived physical and mental functioning, as well as eight more specific health scales (Ware & Sherbourne, 1992).

Table 14.1 Measures Commonly Used to Assess HRQOL

Researchers have tended toward augmenting generic measures with disease- or condition-specific measures in order to capture both overall health status and perceived effects of a certain condition (Bliven, Green, & Spertus, 1998). Disease-, condition-, or symptom-specific tools provide more sensitivity than do generic tools for clinicians looking for changes in disease patterns, such as frequency of loose stools or angina. Similarly, use of treatment or therapy-specific tools is helpful to care providers in evaluating specific responses by individual patients to treatments or changes as a result of intervention (see Using Middle Range Theory in Research 14.1).

A quality-adjusted life-year (QALY) instrument is used by some researchers to measure the extent of health improvement due to an intervention combined with the costs associated with the intervention, resulting in a mathematical formula that is used to assess their relative worth of the intervention from an economic perspective (Phillips &

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Thompson, 2007). For example, a year of perfect health may be worth a score of 1, but a year of less than perfect health life expectancy may be worth −1 point, and death may be worth 0 points. These measures are somewhat controversial and limited in chronic illness, where QOL is more important than is survival, and limited by heterogeneity in the samples being measured (Phillips & Thompson, 2007). They are used most often in pharmacoeconomic studies.

Finally, qualitative measures are valuable for development of theoretical definitions and new HRQOL measures, as well as for validity testing of an existing tool in a new or changing population. Qualitative measures may be used to augment a quantitative measure. Typically, qualitative methodologies in HRQOL include personal interviews and focus groups, with possible open-ended questions.

Guidelines for Measurement Investigators selecting measures for HRQOL studies must make sure they have a clear conceptual definition of HRQOL, and their selection of operational measures should match. Unfortunately, this has not always been the case in the early surge of HRQOL studies. An investigator attempting to measure HRQOL among hospice patients should consider which domains are conceptually important, or have been shown in past research or through clinical experience, to be important in that population. For example, an HRQOL investigator wishing to assess HRQOL among hospice patients would appropriately select a measure that includes the spiritual domain or augment a generic measure with assessment of subjective spiritual status. Similarly, if an investigator plans to use a generic HRQOL measure among patients undergoing treatment for prostate cancer, this generic measure would most appropriately be augmented by a subjective measure that includes self-evaluation of the social and sexual dimensions.

Gill and Feinstein (1994) provided guidelines for proper measurement of HRQOL, including allowing patients to rate the importance of domains, as in the Ferrans and Power QOL Index (1992). Gill and Feinstein also recommended allowing patients to supplement standardized measures. While supplementing quantitative measures with qualitative measures may not be feasible in every study, this practice may provide a test of content validity to the quantitative measure. Study participants may alert

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investigators of important concerns that were not addressed on the quantitative questionnaire. Similarly, qualitative research in HRQOL, such as interviews, focus groups, and journaling, may provide foundational information for researchers striving to measure HRQOL in a previously understudied population (Sandau, Hoglund, Weaver, Boisjolie, & Feldman, 2014). Although Gill and Feinstein encouraged HRQOL investigators to provide an aggregate score so that study results can be compared with others, some debate the conceptual clarity of mathematically combining several measures to produce an artificially aggregated score. However, obtaining a global satisfaction measure in addition to disease-specific measures may be helpful for comparing results for specific interventions in a discrete population.

Researchers studying HRQOL must be prepared to address challenges in psychometric properties among the vast variety of measure available. Challenges to reliability include aberrancies in data collection (such as one research assistant giving more extensive coaching to some participants than others), the absence of a baseline HRQOL measure, and the use of only pieces of HRQOL measures (unless they have been tested for reliability as a subset). Challenges to validity in HRQOL research include potential concurrent life changes. For example, an investigator wishing to study the effect of an intervention for back pain may have confounding results when a generic HRQOL measure is complicated by a life change in a participant (e.g., loss of spouse) that is unrelated to the treatment for back pain. Practical considerations in use of HRQOL measures include timing of study measures. For example, if one is evaluating how a surgery such as mastectomy may affect HRQOL, it may not be appropriate to obtain measures while the patient is still recovering from postoperative incisional pain, unless the investigator's intention is a purposeful longitudinal assessment. Other practical considerations include subject burden (length of the survey) and clinical relevance (what degree of change in a score will be considered clinically significant). Further discussion of desired psychometric properties of HRQOL measures is provided by DeVon and Ferrans (2003). In summary, selection of a measure includes finding a good match with one's conceptual definition of HRQOL, identifying the life domains and concerns most important to the study population, being clear on the research purpose, investigating past performance of the measure for validity and reliability, and evaluating feasibility of the measure.

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Health-Related Quality of Life as an Outcome Measure in Nursing The goal of nursing interventions in HRQOL research is to have a positive impact on a patient's perceived satisfaction with HRQOL (see Table 14.2). This is a central component of HRQOL in that the patient provides a subjective and personal expression of both the level of satisfaction (Staniszewska, 1998) and the degree to which the specific nursing interventions contribute to that level (Robinson, Whyte, & Fidler, 1997). Thus, patient-perceived satisfaction with HRQOL becomes a significant indicator of the success of an intervention. Patient satisfaction is conceptualized as a mediating variable, based on the work of Donabedian (1980), who consistently regarded patient satisfaction as an outcome. He contended that satisfaction with care represents the patient's judgment of quality of care (Yang, Simms, & Yin, 1999, p. 3).

Table 14.2 Examples of Research for Application to Practice

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The Cochrane Database has reviews evaluating the effectiveness of specific nursing interventions on QOL or HRQOL. By reviewing results in the Cochrane Database for nursing interventions and quality of life, one can learn, for example, whether breast care nurses can improve QOL for patients (Cruickshank, Kennedy, Lockhart, Dosser, & Dallas, 2008). A more extensive review of Cochrane studies using the terms nursing and

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quality of life provides readers with a realistic and somewhat sobering overview of attempts by nurses to improve QOL. The reader is left with a sense that (a) comparatively few nursing interventional studies with QOL as an outcome variable currently exist with randomized or comparison groups and (b) most nursing interventional studies may be better off avoiding a hypothesis that the outcome of global QOL will be an improved outcome based on a single nursing intervention.

What may be a realistic goal for nursing interventions is to make a clinically meaningful improvement in a particular domain, such as the social or mental domain, rather than expect changes to the huge construct of QOL (or even HRQOL), which are immense outcome variables potentially affected by a myriad of confounding factors. Life continues to present some complex conditions for which there is no simple cure. It is for these conditions (i.e., HIV, end of life, heart failure, diabetes, depression) that we should perhaps most energetically focus our efforts. Our work to identify, and combat alongside our patients, the persistent conditions of depression and anxiety, for example, that occur concomitant with chronic conditions, provides us with challenges for years to come.

Researchers wishing to evaluate the impact of specific nursing interventions on HRQOL should consider which specific domain or part of a domain their interventions will most likely impact. For example, though the Cochrane review of interventions by breast care nurses (Cruickshank et al., 2008) was unable to support a significant impact on overall QOL, the review reported early evidence (tempered by lack of large sample sizes) that interventions by breast care nurses significantly improved anxiety and helped early recognition of depressive symptoms (major factor in the psychosocial domain of HRQOL). Likewise, though a Cochrane review of structured nursing interventions among patients with lung cancer (Solà et al., 2004) found no improvement in overall QOL, significant results were seen for symptom management of breathlessness as well as some improvements in emotional functioning. These are respectable and important contributions to people living with a complex and potentially isolating disease. Further, researchers have found depression to be an independent predictor for both physical as well as mental well-being (Mallik et al., 2005); thus, nursing interventions may have an effect difficult to measure but nonetheless contributory toward overall life quality.

Nursing researchers investigating HRQOL often use approaches and interventions from other models and theories, allowing connections to be

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made between HRQOL and these models or theories. For instance, Stuifbergen et al. (2000) related health-promoting behaviors from Pender's theory with HRQOL as an outcome. HRQOL as a middle range theory allows for concurrent application of theories that support health within illness, a concept thread that runs through the work of Peplau, Rogers, Parse, Newman, and others (Moch, 1989; Newman, 1984; Parse, 1994; Peplau, 1994; Rogers, 1970). As previously discussed, HRQOL is subjective, and therefore, we must listen to the patient's own summaries. As theorist and researcher Ferrans concludes, “A disability that makes life not worth living to one person may only be a nuisance to another” (Ferrans, 1990b, p. 252.)

Summary HRQOL is subjective, multidimensional, and temporal. Quality of life is a concept with a long history, which has become of interest to a number of disciplines. HRQOL is well matched to nursing because it involves variables that have traditionally been important to nursing. HRQOL often comprises three components: (a) life domains, (b) interventions, and (c) perceived satisfaction. Nurses can utilize the middle range theory of HRQOL to judge the effectiveness of an illness treatment can make use of this middle range theory and the instruments designed to measure it.

Critical Thinking Exercises

1. Does HRQOL have subjective and objective components? 2. What are the underlying assumptions and potential ramifications of

having proxy subjective health status or evaluation measures for children or those unable to speak for themselves?

3. Should further measurement tools only be accepted if based on commonly accepted conceptual definitions?

4. What are appropriate ways for researchers to test validity of HRQOL measures within their population? (Should an HRQOL measure be tested against an objective health status measure?)

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Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise to critique the model of HRQOL.

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Zhan, L. (1991). Quality of life: Conceptual and measurement issues. Journal of Advanced Nursing, 17, 795–800.

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Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370.

Bibliography Ferrans, C. E. (1992). Conceptualizations of QOL in cardiovascular

research. Progress in Cardiovascular Nursing, 2(7), 2–6. King, C. R., & Hinds, P. S. (2003). QOL: From nursing and patient

perspective. Sudbury, MA: Jones and Bartlett Publisher, Inc. McDowell, I., & Newell, C. (1996). Measuring health: A guide to rating

scales and questionnaires (2nd ed.). New York, NY: Oxford University Press, Inc.

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15 Health Promotion Marjorie McCullagh

Definitions of Key Terms

Health-promoting behavior Behaviors or actions that people carry out with the intention of improving their health.

Prior related behavior Experience with the health-promoting behavior.

Personal factors: biological, psychological, sociocultural Factors about the person that influence health- promoting behavior. Examples of biologic factors are age, body mass index, and aerobic capacity. Examples of psychological factors are self-esteem, self-motivation, and perceived health status. Examples of sociocultural factors are race, ethnicity, acculturation, education, and socioeconomic status. The variables may be specific to each health- promoting activity, that is, factors influencing healthy dietary behaviors may not be the same as those affecting exercise behavior.

Perceived benefits of action Beliefs about the positive or reinforcing consequences of a health-promoting behavior.

Perceived barriers to action Beliefs about the unavailability, inconvenience, expense, difficulty, or time-consuming nature of a health-promoting behavior.

Perceived self-efficacy A person's judgment of his or her own abilities to accomplish a health-promoting behavior.

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Activity-related affect Subjective feelings associated with the health-promoting activity.

Interpersonal influences Beliefs concerning the behaviors, the beliefs, or the attitudes of others regarding a health-promoting behavior. Ideas include social norms, social support, and modeling.

Situational influences Beliefs about the situation or context of the health-promoting behavior. These ideas may include perceptions of the available options, demand characteristics, and aesthetic features of the environment in which a given behavior is proposed to take place.

Commitment to a plan of action A commitment to carry out a health-promoting behavior. The plan should be specific to time and place and specify whether it will be with specified persons or alone.

Immediate competing demands Distracting ideas about other things that must be done (e.g., child care) immediately prior to their intention to carry out a health-promoting behavior.

Immediate competing preferences Distracting ideas about other attractive activities to engage in (e.g., shopping) immediately before engaging in a health-promoting behavior.

Introduction During the past century, the major cause of health problems has shifted from infectious diseases to chronic illnesses. Many chronic illnesses are closely related to lifestyle factors such as diet, exercise, and stress management. In order to improve the health of a population experiencing high rates of chronic illness, it is apparent that changes in lifestyle factors are required.

Nurses, as well as many other health professionals, are interested in learning more about how they can help their patients, families, and communities improve their lives. In seeking a way to promote greater longevity and a higher quality of life, nurses need to design interventions that enhance healthy lifestyles. The Health Promotion Model (Pender,

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Murdaugh, & Parsons, 2014) has achieved popularity among nurses as a model that can guide person-centered health counseling to improve a wide range of health behaviors.

Health promotion has many benefits. The benefits of living a healthier lifestyle exceed prevention of disease and include greater vigor and a subjective feeling of wellness. While these benefits can be enjoyed by the individual, society as a whole also profits from health promotion when people create personal and family lifestyles that are consistent with economic prosperity and interpersonal harmony. Health promotion can decrease social problems, such as violence, suicide, and sexually transmitted diseases. Further, health promotion has the potential to significantly decrease health care costs in the years ahead.

Health promotion is a concept well suited to the needs and interests of nurses and their clients. Nurses commonly work in schools, churches, homes, workplaces, and health care agencies. Many of these settings are ideal locations for the promotion of health. Nurses are skilled in many areas that are necessary for health promotion, such as education, counseling, and advocacy. For example, a parish nurse may offer classes to congregational members in a variety of health-related topics such as parenting and caring for aging family members. A school nurse may facilitate self-help group meetings for bereaved children. An occupational health nurse may advocate for inclusion of mental health services in employee health benefit packages. In addition, clients are likely to be receptive to nursing interventions to promote health, because they trust nurses and are accustomed to seeking assistance of these professionals in dealing with their health care needs.

Historical Background Nola Pender first published her Health Promotion Model in 1982. Some early study results (Garcia et al., 1995) suggested the need for addition of concepts to the model in order to increase its predictive power. Based on the analysis of the empirical support provided by each of the studies based on the model, Pender revised the model, retaining selected model concepts and deleting others. In addition, three new concepts and associated relationships were added to the model. The added concepts included prior related behavior, immediate competing demands and preferences, and

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commitment to a plan of action. These revisions to the model, based on both research and theoretical considerations, were made to increase its explanatory power and its potential for use in structuring health-promoting nursing interventions. The revised model was first published in 1996 and most recently in the seventh edition of Health Promotion in Nursing Practice (Pender et al., 2014).

Pender's Definition of Health Nurses are accustomed to assessing their patients for evidence of disease or dysfunction. However, the assessment process commonly reflects a focus on illness, rather than health. This approach is limiting in several ways. First, it risks reducing the patient to a sum of his or her parts (e.g., respiratory, neurological, cardiovascular, etc.). Second, it fails to determine the meaning the client attaches to health and illness. This approach is a negative approach to health in that it views health as an absence of disease. Some consider health and illness to be opposite concepts. This way of thinking suggests that persons with disabilities and chronic illness and those who are near death cannot achieve health. However, many nurses experienced in working with these clients may oppose this view. Negative approaches to health as the absence of illness are inadequate for health professionals at a time that they are increasingly concerned with quality of life and healthy longevity.

Pender et al.'s (2014) definition of health is positive, comprehensive, unifying, and humanistic. She believes that health includes a disease component, but does not make disease its principal element. Her definition of health encompasses the whole person and their lifestyle and includes strengths, resiliencies, resources, potentials, and capabilities. Pender defines health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others, while adjustments are made as needed to maintain structural integrity and harmony with relevant environments.

A major strength of Pender's definition of health is that it offers an expanded view of health. This expanded view provides for greatly increased opportunities to improve client health, as it is not limited to absence of disease or even limitations in functioning or adaptation. For example, Pender's positive view of health permits the development of

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nursing interventions that are not limited to decreasing risks for disease but also aimed at strengthening resources, potentials, and capabilities. This creates broader opportunities for nurses to assist individuals, families, and communities to achieve improved health, enhanced functional ability, and better quality of life.

Health Promotion Health professionals have long recognized the benefits of early detection and treatment of illness, or secondary prevention. However, recently, there has been increased appreciation for the role of primary prevention and health promotion in improving health and quality of life. Primary prevention involves activities aimed at the prevention of health problems before they occur and the avoidance of disease. An example of primary prevention is the administration of tetanus immunization to prevent tetanus infection. Health promotion is intended to increase the level of well-being and self-actualization of an individual or group. Examples of health promotion activities include physical activity and healthy nutrition.

While health promotion and primary prevention are distinct theoretical concepts, in practice they often overlap. Many activities directed toward health promotion will also have preventive effects. Indeed, many adults engage in healthy behaviors with the dual intent of increasing wellness and avoiding illness. For example, an adult may adopt a low-fat diet with two purposes in mind. One intention may be to lower blood cholesterol and, therefore, prevent future cardiovascular problems (primary prevention, also referred to by Pender as health protection). An accompanying intention may be to gain the benefits of weight loss, such as feeling more energetic (health promotion). Other examples of health behaviors that may have both health promotion and preventive benefits include physical activity, adequate rest, and management of stress.

Health promotion is activity directed toward actualization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others, while adjustments are made as needed to maintain structural integrity and harmony with relevant environments (Pender et al., 2014). The concept of health promotion is based on Pender's expanded definition of health that focuses on the whole person and promotes the positive aspects of health. This definition applies to all persons, including persons who are well and those who are experiencing

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an illness or disability. Pender advocates the use of health promotion at a variety of levels and

settings. Although health promotion is most commonly directed toward the individual, Pender suggests that interventions directed toward the family and community are most likely to be successful in creating a healthy society. Furthermore, Pender discusses health promotion in a variety of settings, including schools, workplaces, homes, and nurse-managed community health centers. In a broad sense, health promotion involves education, food production, housing, employment, and health care. It is multidimensional, encompassing individual, family, community, environmental, and societal health. This view of health promotion is consistent with an increasing global emphasis on creating a “culture of health” in all nations.

Description of the Health Promotion Model Pender's model is based on theories of human behavior. There is increased recognition of the role of behavior in primary prevention and health promotion, and there is increased attention among health professionals in helping clients adopt healthy behaviors. Motivation for healthy behavior may be based on a desire to prevent illness (primary prevention) or to achieve a higher level of well-being and self-actualization (health promotion). The Pender Health Promotion Model is primarily based on two theories of health behavior: expectancy–value theory and social– cognitive theory. The first, expectancy–value theory, is based on the work by Fishbein and Ajzen (1975). The theory explains that people are more likely to work toward goals that are of value to them. This proposition by Fishbein and Ajzen relates to Pender's proposition that people will engage in behaviors from which they anticipate deriving personally valued benefits (Pender et al., 2014). Expectancy–value theory also explains that people are more likely to invest their effort in goals that they believe are achievable and will result in the desired outcome.

The second parent theory is Bandura's (1986) social–cognitive theory. A major tenet of social–cognitive theory is self-efficacy. Self-efficacy is the confidence a person has in his or her ability to successfully carry out an

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action. Bandura's theory proposes that the greater a person's self-efficacy for a behavior, the more likely the person will engage in it, even when faced with obstacles. The concept of self-efficacy is one of the behavior- specific cognitions of Pender's model. Pender's belief is that when a person has high perceived competence or self-efficacy in a certain behavior, it results in a greater likelihood that the person will commit to action and actually perform the behavior.

Some have observed that the Health Promotion Model resembles the Health Belief Model. While it is true that the Health Promotion Model shares some concepts with the Health Belief Model, the Health Promotion Model differs from the Health Belief Model in at least one important way. The Health Promotion Model is a competence- or approach-oriented model that focuses on attainment of high-level wellness and self- actualization. This is contrasted with the Health Belief Model, which was intended for use in explaining patients' use of medical diagnosis and treatment of disease, such as tuberculosis. Further, the Health Belief Model incorporates fear or threat of disease as a motivation for action. While this perspective may be valid for diseases that have shorter prodromal periods, the Health Promotion Model does not consider fear or threat as a powerful motivation for distant threats to health.

The Health Promotion Model (Pender et al., 2014) consists of two major categories of predictors (individual characteristics and experiences, behavior-specific cognitions and affect) and the behavioral outcome. Pender identifies the behavior-specific cognitions and affect as the major motivational mechanisms for health promotion behavior. These include perceived benefits of action, perceived barriers to action, perceived self- efficacy, activity-related affect, interpersonal influences, and situational influences. Individual characteristics and experiences included in the model are prior related behavior and personal factors. The model also includes additional concepts influencing the behavioral outcome, such as immediate competing demands and preferences and commitment to a plan of action. These concepts are briefly described in Definitions of Key Concepts, which appears earlier in this chapter. Relationships of the concepts are described in the model's theoretical propositions (Box 15.1). The schematic representation of the model (Fig. 15.1) shows the relationship of model concepts to the behavioral outcome, health- promoting behavior.

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BOX 15.1 Theoretical Propositions of the Health Promotion Model

Prior behavior has “both direct and indirect effects on the likelihood of engaging in health-promoting behaviors. Prior behavior indirectly influences health-promoting behavior through perceptions of self- efficacy, benefits, barriers, and activity-related affect” (p. 52). Personal factors (such as age, self-esteem, and socioeconomic status) may influence cognitions, affect, and health behaviors. “Perceived benefits directly motivate behavior as well as indirectly motivate behavior through determining the extent of commitment to a plan of action to engage in the behaviors from which the anticipated benefits will result” (p. 53) “Perceived barriers to action affect health-promoting behavior directly by serving as blocks to action as well as indirectly through decreasing commitment to a plan of action” (p. 53). “The more positive the affect, the greater the perceptions of efficacy is present. Self-efficacy influences perceived barriers to action, with higher efficacy resulting in lowered perception of barriers. Self- efficacy motivates health-promoting behavior directly by efficacy expectations and indirectly by affecting perceived barriers and level of commitment or persistence in pursuing a plan of action” (p. 54). “Activity-related affect influences health behavior directly as well as indirectly through self-efficacy and commitment to a plan of action” (p. 54). “Interpersonal interaction influences health-promoting behavior directly as well as indirectly through social pressures or encouragement to commit to a plan of action” (p. 55). “Situational influences directly influence health behavior, and indirectly influence health behavior through commitment to a plan of action” (p. 56). “Commitment to a plan of action propels the individual into and through the behavior unless a competing demand that cannot be avoided or a competing preference that is not resisted occurs” (p, 56).

Source: Pender, N., Murdaugh, C., & Parsons, M. (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

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Figure 15.1 Health Promotion Model. (Source: Pender, N., Murdaugh, C., & Parsons, M. (2014). Health promotion in nursing practice (7th ed.). © Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ).

The model includes multiple concepts and relationships, though some concepts and relationships may be more salient than others to a given health behavior. However, the model does not provide assistance in selecting which concepts and relationships are appropriate for specific behaviors. Therefore, the researcher who seeks to use the model should select concepts and relationships based on previous research, theoretical foundations, clinical experience, and practical limitations in regard to a specific behavior. Indeed, extant research using the Health Promotion Model shows the selectivity of researchers in determining which model concepts to include in their study designs.

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Implications of the Model for Clinical Practice The Health Promotion Model offers a conceptual framework for the provision of effective nursing care directed at improved health and functional ability. First, the model provides a method for the assessment of client's health-promoting behaviors. The model directs nurses to systematically assess clients for their perceived self-efficacy, perceived barriers, perceived benefits, interpersonal influences, and situational influences that are relevant to the selected health behavior.

Second, the model identifies several additional client characteristics as targets for assessment. These client characteristics include prior behavior, demographic characteristics, and perceived health status. While these characteristics are not amenable to alteration, they offer a basis for tailoring of nursing interventions, as discussed below.

Third, the model suggests that nursing interventions can be designed to alter clients' perceptions in these areas. Success in these interventions is expected to result in more frequent health behaviors and resultant improved wellness.

Although the model identifies foci for nursing interventions, it does not explicitly describe how nurses can effect changes in client perceptions. While these nursing interventions directed at changing client perceptions are proposed by the Health Promotion Model, few studies that test the effectiveness of these proposed interventions have been completed.

Pender prescribes use of the nursing process as the method of producing behavior change. She emphasizes nursing assessment of health, health beliefs, and health behavior using established frameworks, such as North American Nursing Diagnosis Association (NANDA) and Gordon's functional health patterns. In addition, she recommends the use of model- based assessments such as the Health-Promoting Lifestyle Profile II (HPLP-II). Pender emphasizes use of the nursing process in empowering self-care across the life span. She outlines a multistep process for health planning that includes reinforcing client strengths, developing a plan based on client preferences and Prochaska et al.'s (1994) stages of change, addressing facilitators and barriers, and committing to goals.

Areas of intervention for health promotion include exercise, nutrition,

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stress management, and social support. Pender et al. (2014) review several interventions in each of these areas, based on a variety of models, many of which are research based. These are directed toward increasing the client's capacity for a vigorous and productive life.

Use of the Health Promotion Model in Tailoring Nursing Interventions Model variables, such as client characteristics, cognitions, and affect, may be used to tailor or target nursing interventions to clients. Tailoring of interventions involves shaping of health messages based on characteristics unique to that person. Several comparison studies have found tailoring interventions to increase intervention effectiveness (Kroeze, Werkman, & Brug, 2006; Neville, O'Hara, & Milat, 2009; Velicer, Prochaska, & Redding, 2006). This innovative intervention strategy offers exciting possibilities for designing health promotion interventions to meet the unique needs of each individual client. Once the nurse assesses the client on each of the relevant factors of the model, this information can be used to custom-design a health promotion program for that individual client. Recent applications of the Health Promotion Model have used computers to quickly and accurately assess the health of the client on model-based variables. With the help of computer technology, nurses have used this information to design a health promotion intervention that is unique to the needs of this individual (Kerr, Savik, Monsen, & Lusk, 2007). This computer-assisted approach offers nurses the opportunity to provide interventions that are more appropriate to the individual and may, as a result, enhance intervention effectiveness. In a similar manner, model variables may be used to design interventions for groups of clients who share characteristics.

Selecting the Health Promotion Model Nurses are faced with selecting among a variety of models for use in clinical practice and research. This selection may be based on a variety of factors, including philosophy, research, clarity, and utility.

The Health Promotion Model is appealing to many nurses because it

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offers a view of health consistent with their motivation for pursuing the profession of nursing. Its holistic and humanistic view is congruent with many nurses' own personal philosophy of health and nursing. The model reflects a belief that persons are capable of introspection and are capable of personal change. In turn, the model proposes that health care is more than treatment and prevention of disease but involves creating conditions where clients can express their unique human potential. The nurse is presented as an agent for creating behavioral and environmental changes.

The Health Promotion Model has been used successfully in several research studies, as discussed earlier in this chapter. While some models have been tested more extensively, the Health Promotion Model does have a body of extant literature that provides support for its use. A more thorough discussion of studies using the Health Promotion Model is presented in Pender's seventh edition (Pender et al., 2014). Examples of research applications of the Health Promotion Model are presented in Table 15.1. See also Using Middle Range Theory in Research 15.2.

Table 15.1 Examples of Research for Application to Practice

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USING MIDDLE RANGE THEORY IN RESEARCH 15.2

Source: Walker, S. N., Pullen, C. H., Hageman, P. A., Boeckner, L. S., Hertzog, M., Oberdorfer, M. K., & Rutledge, M. J. (2010). Maintenance of activity and eating change after a clinical trial of tailored newsletters with older rural women. Nursing Research, 59(5), 311–321.

Research Question Midlife and older rural women are at increased risk for chronic

illness, functional limitations, and disability and experience lower access to health care and are less likely to receive preventive services. The purpose of this study was to compare the maintenance of change in healthy eating and physical activity following generic mailed newsletter interventions versus newsletters tailored on Health Promotion Model behavior-specific cognitions, eating behavior, and activity behavior.

Research Design and Sample/Participants The Wellness for Women Project was a community-based clinical

trial using a repeated measures experimental comparison group design with randomization of two demographically similar rural geographical areas in a Midwestern state to intervention (tailored newsletters) or

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comparison (generic newsletters) groups. The intervention lasted for 12 months, and follow-up extended an additional 12 months. Institutional Review Board approval was obtained, and each participant provided written informed consent for both phases of the study (Walker, Sechrist, & Pender, 2009).

Details of the intervention during year 1 of the clinical trial have been reported previously (Walker et al., 2009). The major intervention components were tailored or generic newsletters mailed to the women's homes; these were supplemented by plans of action (goal setting) in the tailored group and by physical activity instructional videotapes provided to both groups. During the year 2 follow-up, women came to the two rural research offices at 6-month intervals for assessments only. No intervention was delivered. A descriptive report that included each woman's assessment results and an indication of desirable ranges was sent to all participants in both groups within 1 month following their 12- , 18-, and 24-month assessments. No advice concerning needed behavior change was included with those mailings. It is recognized that, although not intended as such, reassessment of behavioral and biomarkers may have had an effect as intervention boosters for both groups.

In the Wellness for Women Project, a randomized controlled clinical trial, outcomes for 225 women aged 50 to 69 years were compared at 18 and 24 months. Enrollment on a rolling basis occurred from 2002 to 2003; the intervention phase was conducted from 2002 to 2004 and the follow-up phase from 2003 to 2005. There were 115 women in the tailored newsletters intervention group and 110 women in the generic newsletters comparison group. Attrition during the intervention phase of the study was 9 (7.8%) and 1 (1.8%), respectively, for the two groups. All 215 of the women who completed the 12-month intervention completed the 18- and 24-month follow-up assessments with no further attrition.

Data Collection Behavioral markers and biomarkers of healthy eating and physical

activity to measure primary and secondary outcomes were assessed at the end of the 12-month intervention and at 18 months (excluding serum lipids) and 24 months during follow-up. All assessments were conducted at two rural research offices, and data were transmitted to investigators via the university's restricted access intranet. A research

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nurse at each site assessed biomarkers and supervised women individually in completing self-report questionnaires on the computer. Established valid and reliable measures were used for all assessments.

Findings At 18 months, the tailored group maintained levels of all eating and

activity behaviors, whereas the generic group maintained levels of selected behaviors (e.g., fruit and vegetable servings, activity, stretching exercise, lower body strength and flexibility) but increased saturated fat intake and declined in weekly strength exercise and cardiorespiratory fitness. At 24 months, the tailored group maintained levels of strength exercise and lower body strength, whereas the generic group decreased in both. A greater proportion of women who received tailored newsletters achieved most Healthy People 2010 criteria for eating and activity. Results demonstrated that tailored newsletters were more effective than were generic newsletters in facilitating change in eating and activity for 6 months postintervention and in maintaining change in strength exercise for 12 months postintervention.

Measurement of Model Concepts Instruments have been developed to measure a variety of concepts

related to the Health Promotion Model. Primary of these is the HPLP-II (Susan Walker, personal communication, June 24, 2002). Due to the broad nature of the model, many instruments have been developed to measure behavior-specific attitudes and beliefs. A sample of these is described in Table 15.2.

Table 15.2 Health Promotion Model Instruments

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Most nurses will find that the Health Promotion Model is straightforward and easy to understand. It uses terms that are readily comprehended, and its propositional statements are presented clearly. The phenomena addressed by the model are familiar to nurses, and most nurses will require minimal learning of new terms and concepts in order to use and understand the model. The model is clearly presented in graphic form.

The Health Promotion Model has been used in a variety of settings, including schools, workplaces, ambulatory treatment facilities, a rehabilitation center, and a prison; see Using Middle Range Theory in Practice 15.3 for an example. Its use has been with a wide variety of health behaviors, including exercise, nutrition, and use of hearing protection. The studies have involved diverse clients in regard to gender and age. The model has a limited history of application in culturally diverse groups. However, samples of Korean, Taiwanese, Thai, and Japanese individuals have participated in prior studies. It is noteworthy that persons included as study participants have been well or experiencing chronic illness, such as

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HIV infection.

USING MIDDLE RANGE THEORY IN PRACTICE 15.3

Problem Josephina, age 52, is diagnosed with diabetes, hypertension, and

hyperlipidemia, which are not well controlled. In addition to prescription medication, her physician has recommended using physical activity to manage her condition.

Nursing Assessment The outpatient clinic nurse assessed Josephina for the importance

(value) of physical activity in her life; the extent to which she feels capable of physical activity (self-efficacy); her goals for a work, family, and personal life (definition of health); her perceived benefits and barriers to physical activity; access and availability of facilities for physical activity; the presence of other persons in her life who may serve as physical activity role models; social support for physical activity; and her use of reminders (cues) for engaging in physical activity.

Based on the assessment, the nurse learns that the cost of a gym membership (barrier), and child care and other family responsibilities (immediate competing demands) frequently interfere with her engaging in physical activity. In addition, the nurse learns that Josephina lives in a cold climate, which limits her opportunities to engage in physical activity outdoors (situational influences), and feels that even if she engages in physical activity, she will continue to experience diabetes, hypertension, and hyperlipidemia (self-efficacy).

Nursing Intervention The nurse initiates several interventions on behalf of Josephina

based on the assessment. First, with Josephina's consent, the nurse connects her with a middle-aged woman from her practice who has made significant gains in her disease management through self-care activities, including physical activity and diet (addressing her self-

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efficacy). Through a series of questions, the nurse also helps Josephina identify several physical activities in which Josephina feels she could engage with her children, such as playing ball and walking the dog (addressing a barrier and immediate competing demands). Working together, the nurse and Josephina identify ways to incorporate physical activity into her day (e.g., climbing stairs, parking a distance from work), thereby addressing her situational influences. They also develop a goal for minutes of exercise each week and a log for tracking her exercise, and plan to meet again in a few weeks to monitor the success of her plan (addressing her self-efficacy).

The Health Promotion Model has been used by nurses working in a variety of community-based settings, such as occupational health and public health. The model is well suited to clients whose health status is stable and whose basic needs are met. Although Pender's definition of health is broad and encompasses persons who are experiencing illness, application of the Health Promotion Model is untested in acute care settings and with clients whose health concerns are urgent or living conditions are unstable.

Summary The HPM is designed to guide nurses in helping clients achieve improved health, enhanced functional ability, and better quality of life. The model encompasses both behavioral and environmental changes to effect improvements in a society where lifestyle factors account for a large proportion of health problems. The model is based on established theories of human behavior, including expectancy–value theory and social–cognitive theory. The HPM claims that a variety of client characteristics and cognitive– affective factors combine with competing demands and preferences as well as commitment to a plan of action to explain the likelihood of health-promoting behavior. The model has been tested in several clinical studies using a variety of settings, health behaviors, and client characteristics. It presents exciting possibilities for the creation of interventions that are tailored to the unique characteristics and needs of individual clients.

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The model was last revised in 1996 based on review and analysis of results of model testing and intervention effectiveness research. Future development is needed in measures of model concepts that fit specific target populations and design of robust interventions that can change model beliefs and, subsequently, health outcomes. Interventions that address not only individuals but also families and communities in creating multilevel interventions employing the HPM in combination with community action models are most likely to achieve success.

Critical Thinking Exercises

1. The Pender Health Promotion Model identifies benefits and barriers as factors influencing health behavior. Respond to the following items, considering clients from your own clinical practice. What are the barriers to and the benefits of adopting a selected healthy behavior, such as exercise?

2. Generate several questions designed to elicit specific information about your clients' perceptions of their barriers and benefits.

3. How can you use this information to improve the effectiveness of your efforts to influence your clients' adaptation of healthy behaviors?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise to critique the Health Promotion Model.

Acknowledgment The author gratefully acknowledges the critical review of the fourth edition of this chapter by Dr. Nola Pender.

REFERENCES

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Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention and behavior: An introduction to theory and research. Reading, MA: Addison- Wesley.

Garcia, A. W., Broda, M. A., Frenn, M., Coviak, M., Pender, N. J., & Ronis, D. L. (1995). Gender and developmental differences in exercise beliefs among youth and their prediction of their exercise behavior. Journal of School Health, 65, 213–219.

Kerr, M. J., Savik, K., Monsen, K. A., & Lusk, S. L. (2007). Effectiveness of computer-based tailoring versus targeting to promote use of hearing protection. The Canadian Journal of Nursing Research, 39, 80–97.

Kroeze, W., Werkman, A., & Brug, J. (2006). A systematic review of randomized trials on the effectiveness of computer-tailored education on physical activity and dietary behaviors. Annals of Behavioral Medicine, 31, 205–223. doi: 10.1207/s15324796abm3103_2

Lusk, S. L., Ronis, D. L., & Hogan, M. M. (1997). Test of the health promotion model as a causal model of construction workers' use of hearing protection. Research in Nursing and Health, 20, 183–194.

Neville, L. M., O'Hara, B., & Milat, A. J. (2009). Computer-tailored dietary behaviour change interventions: A systematic review. Health Education Research, 24, 699–720.

Pender, N., Murdaugh, C., & Parsons, M.A. (2014). Health promotion in nursing practice (7th ed.). Upper Saddle River, NJ: Prentice Hall.

Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W., …, Rosenbloom, D. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39–46.

Sechrist, K., Walker, W., & Pender, N. (1987). Development and psychometric evaluation of the exercise benefits/barriers scale. Research in Nursing and Health, 10, 357–365.

Velicer, W. F., Prochaska, J. O., & Redding, C. A. (2006). Tailored communications for smoking cessations: Past successes and future directions. Drug and Alcohol Review, 25, 49–57.

Walker, S., Sechrist, K., & Pender, N. (1997). The health-promoting lifestyle profile: Development and psychometric characteristics. Nursing Research, 39, 268–273.

Walker, S., Pullen, C., Hageman, P., Boeckner, L., Herzog, M., Oberdorfer, M., ..., Rutledge, M. (2009). Maintenance of Activity and Eating Change Following a Clinical Trial of Tailored Newsletters with Rural Women. Nursing Research, 58(2), 74–85.

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Wei, C. N., Yonemitsu, H., Harada, K., Miyakita, T., Omori, S., Miyabayashi, T., …, Ueda, A. A. (2000). Japanese language version of the health-promoting lifestyle profile. Nippon-Eiseigaku-Zasshi, 54, 597–606.

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16 Deliberative Nursing Process

Mertie L. Potter

Definition of Key Terms

Automatic nursing process Actions (visible behaviors) the nurse takes based on reasons other than the patient's immediate needs.

Deliberative nursing process Means by which the professional nurse purposefully explores with the patient the nurse's perceptions (stimulation of any one of the five senses), thoughts, and/or feelings related to the patient's immediate need for help.

Dynamic nurse–patient relationship Interactive contact/connection between nurse and patient, when the nurse begins to explore the meaning behind the patient's verbal and nonverbal behaviors.

Immediate need for help Requirement of the patient in a specific situation. Providing help for the identified need relieves or diminishes the patient's immediate distress and/or improves the patient's immediate sense of adequacy or well-being.

Nursing situation Circumstance that involves a patient's behavior, the nurse's reaction (perceptions, thoughts, and feelings combined together), and the nurse's action (activity the nurse completes with or for the patient).

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Patient distress Feeling experienced by a patient when the patient cannot meet certain needs and is not helped in meeting such needs.

Patient outcomes/product Improved verbal and nonverbal patient behaviors that can result from the nurse's deliberative and effective action(s) with the patient.

Validation Ongoing process of exploring and determining with a patient if the nursing reaction was accurate and if the nursing action was helpful.

Introduction The birthing of Deliberative Nursing Process by Ida J. Orlando culminated in 1961, after a number of years laboring to define both the function and the product of professional nursing (Orlando, 1961). The theory began to take shape through Orlando's experiences within nursing practice and nurse education. She reviewed more than 2,000 anecdotal recordings of faculty, students, and nurses related to their interactions with patients and began to see patterns of effective and ineffective nursing process in various nurse–patient situations (Pelletier, 1976). Emerging from these early experiences, Deliberative Nursing Process since has matured into a significant, enduring, and practical nursing theory.

As a middle range theory, Deliberative Nursing Process has a limited number of variables and is limited in scope (McEwan, 2002; Walker & Avant, 1995). However, it is specific and adequate enough to apply and test in research and practice. Although categorized as a grand theory by some (Walker & Avant, 1995; Wills, 2002), Deliberative Nursing Process demonstrates the following middle range theory characteristics: comprehensive yet focused, generalizable, restricted in its concepts, clear in its propositions, and conducive to testable hypotheses (McEwan, 2002).

An unusual paradox within Deliberative Nursing Process is its proclivity toward both simplicity and complexity as a theory. This paradox partially explains the attractiveness of using this theory. Generally, it is straightforward in its presentation while being multifaceted in its applications. For example, developing a nurse–patient relationship that is

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dynamic and unique is not complicated. However, the dynamics of the nurse–patient relationship itself may be very complex (Orlando, 1961).

A unique feature related to the development of this theory is the inductive manner in which Orlando defined effective nursing (Schmieding, 2002). Orlando determined effective and ineffective nursing from her observations of “good” and “bad” nursing practice (Orlando, 1961, 1972; Pelletier, 1976; Schmieding, 1993a). From her observations of specific phenomena (nurse–patient interactions), she identified relationships with other phenomena to develop propositions that led to the development of larger concepts and, ultimately, the theory (Johnson & Webber, 2001).

Orlando desired that nurses become educated to assist patients to express what help they actually need (Pelletier, 1967). Another distinctive feature of Deliberative Nursing Process is that patient input is critical. It is the nurse's professional responsibility to involve the patient in the process of identifying and meeting the patient's immediate needs for help (Orlando, 1961, 1972, 1990).

Historical Background The need for nurses to have a distinct body of knowledge to direct and enhance nursing practice and the movement of nursing toward becoming a profession were beginning to take place at the turn of the twentieth century (Alligood, 2002). Orlando's Deliberative Nursing Process evolved during an era when nurses were attempting to distinguish nursing from other disciplines and when psychiatric–mental health nurses were determining their place among nurses of other specialties. Deliberative Nursing Process came into being as Orlando realized that nursing needed to address three areas: “nurse–patient relationships, the nurse's professional role and identity, and the development of knowledge which is distinctly nursing” (Orlando, 1961, p. viii).

Orlando first published work related to this theory after she examined what made nursing interventions effective or ineffective. She asserted early on that effective nursing was “good nursing,” and ineffective nursing was “bad nursing” (Orlando, 1976; Schmieding, 1993a). Although this terminology might not be acceptable during today's trend of political correctness and relativity, Orlando was bold in her assertion that nursing was either “good” or “bad.” She also stressed that nursing needed to define

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exactly what “nursing” was, and contended that nursing could not be a profession unless it was able to distinguish what nurses did that was unique (Orlando, 1961).

Orlando was asked to determine what mental health principles were needed in a nursing curriculum. However, she became acutely aware during the project that professional nursing did not have a clear function or product. Nursing was at a crossroads. Orlando (1961) understood that nurses were unclear in their attempts to define what nursing was. For someone concerned with meeting patients' immediate needs, here was an immediate need for nurses—to define and to distinguish nursing's function and product. She recognized that the patient and the patient's needs were getting lost in nurses' assumptions of what those needs were. During a project funded by the National Institute of Mental Health, Orlando began to examine nurses' interactions with patients.

Defining Nursing and Outcome Variables Resolute in her mission, Orlando set forth in her later work to assist nurses further in defining what nursing is and what it should entail to distinguish it from other disciplines. Key goals became the following: to define the distinct professional function of nurses, to encourage nurses to assume authority to carry out that function, and to educate nurses to use process discipline (deliberative nursing process) to assure that the product of nursing function involves the patient and others who impact the patient's care (Orlando, 1972). She developed a user-friendly theory that was readily understandable and broadly applicable.

Orlando held that “to nurse” and “nursing” were very different from “to doctor” and “doctoring” (Orlando, 1961, 1972; Orlando & Dugan, 1989). She asserted that doctors' orders are designed for patients, not nurses, and that nurses keep themselves on a dependent path when they focus on following doctors' orders rather than assisting patients to meet their needs for help, which may include the patient's needing to comply with doctors' orders (Orlando, 1987). Orlando contended that licensure authorizes nurses to fulfill a professional role, but authority is only implicit until the nurse engages in a process with the patient to meet the function of nursing, namely, to help the patient meet immediate needs for help that the patient is unable to meet on his or her own (Orlando, 1972).

Orlando suggested that the concept of “nursing” derives its meaning

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from the nursing of infants and the need to have someone nurture and assist infants in obtaining what they need from the environment to survive. She postulated that, at times, individuals might need assistance from others to obtain what is needed from the environment to meet their needs when they are unable to nurse themselves (Orlando, 1961, p. 4; Orlando & Dugan, 1989). Orlando (1972, 1987) distinguished the difference between lay and professional nursing by stating that a professional nurse is needed when a layperson cannot assure that the patient's distress will be identified or relieved.

In some of her works, she questioned whether or not expanded roles of nursing should be considered in the realm of nursing or that of doctoring at a lower cost (Orlando & Dugan, 1989). She used straightforward and uncomplicated language. She contemplated and encouraged nurses to discern what the words “to nurse” meant and referred to a dictionary to emphasize her point of what nursing should entail. She accepted Funk and Wagnall's definition of “to nurse” to mean: “to encourage, to look after; to nourish, protect, and nurture; to give curative care to an ailment” (Orlando, 1987, p. 408).

The conceptual framework of nursing proposed by Orlando identified promotion of “comfort,” or the relieving of distress, as crucial to the task of nursing. Orlando's work contributed to the evolution of the concept of comfort by subsequent nursing theorists (Tutton & Seers, 2003). In particular, she designated the nursing role as addressing matters prohibiting a client's “mental and physical comfort” (Orlando, 1961, p. 23). In a review of the development of the concept of comfort in nursing, Tutton and Seers (2003) note that while Orlando does not define the “exact nature of comfort,” her promotion of Deliberative Nursing Process to enhance patients' perceived needs makes comfort “pivotal” to her definition of nursing, as it relates to both physical and psychological care (p. 691).

Notably, Orlando was ahead of her time in her concern for and measurement of outcome variables. She promoted progressive ideas, such as defining professional nursing, employing critical thinking within the nursing process, involving the patient in the nursing process, and measuring patient outcomes. Orlando was aware that ineffective nursing activities impacted areas, such as nursing care costs, patient progress, material costs, and medication costs. She was concerned that nursing was acquiring too many nonprofessional tasks that would take the nurse away from helping the patient (Orlando, 1961). Always seeking patient

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involvement in the provision of nursing care, Orlando looked for a “helpful outcome” as validated with the patient to include “change in the behavior of the object indicating either relief from distress or that a solution to a living or work problem had been found” (Orlando, 1972, p. 61). She addressed work problems involving staff members, as well as patient problems in her 1972 reported studies.

Orlando's Legacy Work on Deliberative Nursing Process theory has spanned more than a half century. Orlando's initial development on this theory began in the early 1950s, and work on the theory's development continues. Her early works referred to the “deliberative nursing process.” Orlando began using the term “nursing process discipline” in 1972 because she asserted that nursing process was a discipline that could be learned (Orlando, 1972, p. 2). The term “deliberative nursing process” will be used throughout this chapter for consistency.

It is obvious in both her published and unpublished writings that Orlando not only was intensely passionate about nursing as an individual but also was a determined advocate for nursing (Orlando, 1961, 1972, 1976, 1983, 1987). Several basic tenets come through strongly in her work, primarily (a) that the function of nursing is to meet the patient's immediate need for help when the patient is unable to do so without the nurse's help, and (b) that the product of nursing is to relieve the patient's distress caused by the immediate need for help and to be able to observe improvement either verbally or nonverbally (Orlando, 1961, 1972). Furthermore, her theory promotes the uniqueness of nurses and maintains that patients must be involved in the identification and determination of their immediate needs for help (Orlando, 1961). Orlando was not hesitant to express her grave concern with the definition of nursing promoted in the American Nurses Association Social Policy Statement of 1980—she found “no operational meaning” in it and no differentiation between professional and lay nursing (Orlando, 1983, p. 2). Her passion for nursing clearly was evident throughout her life, accompanied by her assertion that the profession needed to define nursing (I. J. Orlando, personal communication, June 24, 2002).

Ida Jean Orlando Pelletier continues as a symbol of nursing leadership and theory development, having taught and implemented her theory at

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some of the nation's most respected academic institutions; she was formally recognized as a “Nursing Living Legend” by the Massachusetts Registered Nurse Association in 2006—the year prior to her death (Potter, 2008; Tyra, 2008).

Definition of Theory Concepts

Deliberative Nursing Process Deliberative Nursing Process remains relevant and significant as a nursing theory due to its patient-focused approach; nurse exploration of nurse perceptions, thoughts, and feelings with patients; and effective outcomes that result from its use. Orlando (1961) proposes a practical approach, with a broad application within nursing education, practice, and research. She focuses on the nurse's unique and deliberative response to the patient who has expressed an immediate need for help. This is accomplished by the nurse's exploration and validation of the nurse's perceptions, thoughts, and feelings about the patient's behavior with the patient. Furthermore, it is the nurse's responsibility in deliberative nursing to see to it that the patient's need for immediate help is met either by the nurse's own activity or by eliciting the help of others (Orlando, 1961).

Orlando acknowledges and affirms the nurse's distinctive interpretation and validation of observations made. Furthermore, she stresses the independent function performed during a deliberative nursing interaction. She recognizes that what makes nurse–patient relationships dynamic is nurses continually sharing their unique perceptions, thoughts, and feelings (i.e., their immediate reaction) about patients' unique behaviors within a deliberative process with patients (Orlando, 1961, 1972).

Orlando asserts that good nursing initially involves a nurse's determining with the patient a number of elements: (a) What does the patient think is occurring? (b) What does the patient define as the immediate distress? (c) Is the patient's distress related to an immediate need for help? (d) Is the nurse's help needed for the patient to obtain relief? She also observed that nurse–patient interactions involving Deliberative Nursing Process resulted in positive outcomes, namely, both verbal and

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nonverbal positive changes within the patient (Pelletier, 1976). Deliberative Nursing Process was renamed Nursing Process Discipline

by Orlando (1972). She also refers to Deliberative Nursing Process as effective nursing (Orlando, 1961, 1972) or good nursing (Orlando, 1976). She analyzed nurse–patient interactions and determined that effective interactions involved open disclosure of the nurse of perceptions, thoughts, and feelings and validation of the same with the patient. After implementing a nursing action, the nurse validates with the patient if the nursing action met the patient's immediate need for help (Fig. 16.1; Orlando, 1961).

Figure 16.1 The action process in a person-to-person contact functioning by open disclosure. The perceptions, thoughts, and feelings of each individual through the observable action. (Used with permission from Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study (p. 26). New York, NY: Putnam.)

Orlando also noted that ineffective interactions often involved a more secretive style. Both patient and nurse were not aware of each other's perceptions, thoughts, and feelings in such interactions (Fig. 16.2).

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Figure 16.2 The action process in a person-to-person contact functioning in secret. The perceptions, thoughts, and feelings of each individual are not directly available to the perception of the other individual through the observable action. (Used with permission from Orlando, I. J. (1972). The discipline and teaching of nursing process. In An evaluative study (p. 26). New York, NY: Putnam.)

Orlando (1972, p. 28) developed a nursing process record to assist in learning deliberative nursing process (process discipline) and to be better able to discern nursing process done in secret or using open disclosure (Fig. 16.3). Orlando referred to the nurse's perceptions, thoughts, and feelings as part of the nurse's reaction and whatever the nurse said and/or did to, with, or for the patient as the nurse's action (see Fig. 16.3; Orlando, 1972, p. 56).

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Figure 16.3 Process A illustrates the nursing process functioning in secrecy. Process B illustrates the nursing process functioning by open disclosure. (Used with permission from Orlando, I. J. (1972). The discipline and teaching of nursing process: An evaluative study (p. 28). New York, NY: Putnam.)

Automatic Nursing Process Automatic nursing process refers to any actions or interventions a nurse takes to help a patient that may not be related to the process of helping the patient. Automatic nursing process may be impacted by other influences,

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such as nursing care costs, patient progress, or additional expenses. Automatic nursing process also is referred to as nursing process without discipline (Orlando, 1972), ineffective nursing (Orlando, 1961, 1972), and bad nursing (Orlando, 1976).

Orlando asserted that automatic nursing process activities were ineffective when they (a) involved nursing action without determining the meaning of the patient's behavior to the patient or the need that caused the behavior, (b) did not assist the patient to inform the nurse how the activity influenced the patient, (c) did not connect the nursing activity to the patient's need, (d) were implemented because of the nurse's inability to explore the nurse's reaction to the patient's behavior, or (e) did not indicate that the nurse was attuned to how the nursing activity influenced the patient (Orlando, 1961, p. 65). Such activities are not necessarily wrong or negative, but they do not determine if the activity is perceived as helpful in relieving the patient's immediate needs. Furthermore, automatic nursing activities indicated to Orlando that nursing care had been given without a disciplined or deliberative professional process (Orlando, 1976).

An example of the difference between use of an automatic nursing process, which involves nurses' assumptions, and a deliberative nursing process, which involves nurses' exploration of the patients' immediate needs for help, is demonstrated in a study by Bochnak, Rhymes, and Leonard (1962). When two different types of nursing activities to address patients' complaints of pain were examined, statistically significant results occurred at the 0.05 level. In the control group, it was assumed that any complaint of pain indicated a need for pain-relieving medication, and when patients complained of pain, they were given pain-relieving medication. Relief was variable and slow. However, in the experimental group, nurses who used a deliberative approach to determine more accurately what the patients' complaints of pain were about did not automatically administer pain-relieving medication. Their explorations with the patients led to various interventions that provided more extensive relief and quicker relief for the patients (Bochnak et al., 1962).

Dynamic Nurse–Patient Relationship According to a recent study, patients are most concerned with personal care issues related to five essential themes: having their needs met, being treated pleasantly, being cared for, having competent nurses, and having

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care provided promptly (Bolden & Larrabee, 2001). These areas relate to meeting patients' immediate needs for help, which are foundational in Orlando's theory of Deliberative Nursing Process. Orlando (1961) based her ideas about a dynamic nurse–patient relationship on principles from other theories, such as behavioral theory, which postulates that humans are living and behaving organisms who interact continually with one another and within the environment.

Defining the function and product of nursing is explicit in Orlando's definition of the dynamic nurse–patient relationship. Orlando fervently strove to have nurses define the unique function and product of nursing. She defined nursing function as helping the patient and defined nursing product as the improvement or helpful result in the patient's behavior, observable both verbally and nonverbally (Orlando, 1961, 1972, 1983).

Immediate Need for Help Immediate need for help refers to the patient's inability to fulfill a need for help; the patient may or may not need assistance identifying and/or communicating what the actual need for help is (Orlando, 1961). The observed behavior of the patient is assumed until the meaning behind the behavior is explored (1961, p. 23). Behaviors observed by the nurse may be nonverbal or verbal. Nonverbal behaviors include motor activity, physiological manifestations, and vocalizations. Verbal behaviors take into account complaints, requests, questions, refusals, demands, comments, and statements (1961, pp. 36, 37). Immediate needs for help also are referred to simply as “need” in earlier writings (1961).

Therefore, an immediate need for help is any condition in which patients need to have immediate distress relieved or diminished or their sense of sufficiency or welfare improved (Orlando, 1961, p. 5). Immediate need for help definitely implies that the patient cannot meet the need without professional help.

Patient Distress Patient distress occurs when a patient's immediate needs are unmet. It is a sense of discomfort that arises when a patient is unable to communicate his or her needs adequately or clearly. Orlando cited physical challenges,

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unfavorable reactions to the environment, and unfavorable occurrences as examples of circumstances that keep the patient from being able to meet immediate needs (Orlando, 1961, p. 11).

Patient distress is what the patient perceives to be stressful. Orlando holds that behavior has meaning and that nurses cannot assume what the behavior means without exploring with the patient what the behavior and accompanying distress mean to the patient.

Nursing Situation According to Orlando (1961, p. 36), a nursing situation encompasses three elements and is dependent upon the nurse's use of them: (a) the patient's behavior, (b) the nurse's reaction, and (c) the nurse's actions intended for the patient's benefit. The interaction of these three elements comprises nursing process.

Validation Validation is an ongoing nursing action within the Deliberative Nursing Process. It involves checking with the patient if the nurse's perceptions, thoughts, and/or feelings were accurate in relation to the patient's behavior and if the nurse's interventions were “correct, helpful, or appropriate” (Orlando, 1961, p. 56). In addition, Orlando sees the nurse as primarily responsible for initiating the process of exploration and discovery in relation to how the patient is responding to any nursing action (1961). The presence or absence of validation in the nurse–patient relationship and subsequent actions differentiates the deliberative process (with patient validation) from the automatic response (without patient validation), as visualized in Figure 16.4 (Aponte, 2009).

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Figure 16.4 Orlando's Dynamic Nurse–Patient Relationship Nursing Framework. (From Aponte, J. (2009). Meeting the linguistic needs of urban communities. Home Healthcare Nurse, 27(5), 327. Copyright 2009 by Wolters Kluwer Health. Reprinted with permission.)

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Patient Outcomes/Product The end result of a nursing action is to “bring about improvement” (Orlando, 1961, p. 6). That improvement should be observable both verbally and nonverbally in the patient's behavior (Orlando, 1972, p. 21). Patient outcomes also should be both “predictable and helpful” and may include such outcomes as “avoidance, relief or diminution of helplessness suffered or anticipated by the individual in an immediate experience” (Orlando, 1972, p. 9). The nurse's activity may result in help, no help, or be unknown (Orlando, 1961, p. 67). If the outcome does not transpire as predicted, then the nurse must continue to explore what else may be needed to meet the patient's immediate need for help.

Description of the Theory of Deliberative Nursing Process

Simple Yet Complex Theory Deliberative Nursing Process is a theory that is readily understood, has a specific focus (i.e., meeting patients' immediate needs for help), addresses patient problems and probable outcomes (felt distress and lowered distress, respectively), and is explicit to nursing. Its concepts and their relationships are testable and they answer questions about nursing, which are indicators of a middle range nursing theory (Marriner-Tomey, 1998). Orlando's work helped refocus nurses on patients rather than on tasks and on an active, rather than passive, role of patients in their own care.

Complexity refers to the “richness” of a theory to elucidate more variables and their interrelationships (Stevens-Barnum, 1990, p. 97). Part of the theory's complexity involves learning how to use it. Becoming proficient in the use of Deliberative Nursing Process necessitates time, practice, and self-reflection, often in the form of a supervisory experience. The use of nursing process recordings (see Fig. 16.3) helps the nurse distinguish perceptions, thoughts, and feelings—no small task in itself. Learning Deliberative Nursing Process often involves a close supervisory

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experience in which the learner reconstructs and examines interactions. The process of becoming comfortable in owning one's perceptions, thoughts, and feelings and sharing them with patients is at times difficult and complex.

Function of Nursing Orlando observed patients in distress and asserted that it was professional nursing's role to determine and meet their immediate needs for help by exploring with the patient the nurse's unique thoughts and feelings resulting from perceptions related to the observed patient behaviors (Orlando, 1961, 1972, 1990). When the nurse shares perceptions, thoughts, and/or feelings, it is considered to involve open disclosure; by not sharing, the patient is unaware of the nurse's reaction (Orlando, 1972, p. 26). Nurses must not make assumptions, but must explore their perceptions, thoughts, and feelings about the patient's behavior with patients. Orlando's (1961) incorporation of nurses' exploration of their thoughts with patients as part of a deliberative process indicates how critical thinking is an essential part of the deliberative nursing process (Schmieding, 2002).

Major Components and Their Relationships Nursing is independent, has its own unique professional function, and has its own distinct product (Pelletier, 1976, p. 17). The dynamic nurse–patient relationship involves reciprocity between the nurse and patient; each is influenced by what the other does and says (Marriner-Tomey, 1998). It is dependent upon a nurse-initiated exploration of perceptions, thoughts, and feelings about the patient's behavior, and validation that the nurse's perceptions, thoughts, and feelings are accurate.

The nurse initiates the deliberative process to determine the immediate need for help by helping the patient identify and express the meaning of his or her behavior (Orlando, 1961). Further, the nurse helps the patient explore distress related to the immediate need for help to determine the help needed (p. 29). Within the dynamic nurse–patient relationship, the nurse observes a patient whom the nurse thinks is in distress. This dynamic

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relationship is dependent upon “what the nurse and patient start with, to the length of their contact and to what they are able to accomplish” (Orlando, 1961, p. 91).

As Schmieding points out, nurses using Deliberative Nursing Process realize “that the patient is the source of the nurse's power” (Schmieding, 2002, p. 327). The nurse uses reflection as part of a critical thinking process to help ascertain the meaning of the patient's behavior according to the patient and to determine how the behavior relates to the nurse's assumption that an immediate need exists, which is leading to distress for the patient. Nurses obtain information either directly from the patient or indirectly from other sources, such as family, friends, and nursing staff. Orlando considers that nurses have access to a tremendous amount of information about the patient (Orlando, 1961).

The nurse using a deliberative process will check what the meaning of the information is with the patient. In an automatic process, the nurse assumes what the information means. Most likely, the outcomes would be significantly different, depending upon which process the nurse uses. Using the deliberative process, the patient partners with the nurse to identify the need, and a successful outcome is more likely. When an automatic process is used, the patient is not included in the assessment or decision-making processes, making a successful outcome less likely (Orlando, 1961, 1972).

Deliberative Nursing Process is a learned and practiced process (Orlando, 1972). The nurse validates with the patient that the patient has an immediate need for help and that the immediate need for help cannot be met without a professional nurse's help. The nurse intervenes, after exploring with the patient what meaning the patient ascribes to behaviors related to the situation that resulted in an immediate need for help. The nursing situation involves (a) the patient's behavior, (b) the nurse's reaction, and (c) the nurse's activity or actions to assist the patient. Nursing process is the interaction of the three elements contained within a nursing situation (Orlando, 1961, p. 36).

The nurse validates that the immediate need for help has been met by asking the patient and evaluating if the anticipated product or patient outcome of the nursing action, namely, improvement and relief of distress, has occurred. If the nursing action has resulted in the patient's relief, the nursing action has been effective in achieving the desired and predicted patient outcome or product. As mentioned, Orlando used nursing process recordings to study nursing process and to educate nurses in Deliberative

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Nursing Process. Assumptions and propositions will be described, based upon Johnson

and Webber's (2001) definitions. Assumptions are assumed truths that are associated with the relationships (p. 15). Patients' becoming distressed when they cannot meet their own needs is an example of an assumption within Deliberative Nursing Process (Orlando, 1961). A more complete listing of assumptions implied within Orlando's Deliberative Nursing Process theory can be found in Table 16.1.

Table 16.1 Assumptions and Propositions within Orlando's (1961) Deliberative Nursing Process

Propositions direct the relationship between concepts and provide a description of the relationship between concepts (Johnson & Webber, 2001, p. 15). An example that Orlando cited was that “the professional function of nursing is distinct and of central importance to patients in any treatment setting” (Pelletier, 1967, p. 30). Implied propositions within Orlando's Deliberative Nursing Process theory are also listed in Table 16.1.

Applications of the Theory

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Deliberative Nursing Practice has been applied to a broad range of practice settings, including inpatient and acute nursing settings, residential care facilities, as well as in outpatient or community settings by advanced practice nurses. Deliberative Nursing Process application and outcome measures may be utilized to validate clients' needs and perceived outcomes to improve nursing care. Furthermore, it may lead to professionalization of nursing's role in any of these practice settings, as it demonstrates efficacy and potential impact of nursing. The following examples represent a sampling of contexts in which Deliberative Nursing Practice has been incorporated.

Deliberative Nursing Process in Theory Development Deliberative Nursing Process has been linked with recent models of social information processing to develop a new nursing theory. Sheldon and Ellington (2008) applied the Crick and Dodge model of social information processing to interactions within nursing responses to patient behaviors. By evaluating interviews with experienced nurses, nursing scholars identified Deliberative Nursing Process as foundational for understanding nurse–patient relationships. They concluded that social information processing theory was instrumental to further describe how nurses learn to effectively respond to patients' social cues and environmental factors (Sheldon & Ellington, 2008). Their research suggests that the coupling of Deliberative Nursing Process and social information processing may contribute to new nursing theory and curriculum development, in order to enhance nursing training programs and communication skills and improve patient care.

Practice Applications

Deliberative Nursing Process in a Group Context The author supervised nurses in 12-week group leadership training. Nurses

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received contact hours for coleading a weekly patient group session for 12 weeks, completing written assignments and readings, and participating actively in supervision throughout the group experience (Potter, Williams, & Costanzo, 2004). Each group focused upon the following:

Meeting patients' immediate needs for help Validating that nurse coleaders understood what group members stated was their immediate need for help Sharing nurse coleaders' perceptions with patient group members, thoughts, and/or feelings in response to behaviors (verbal or nonverbal) that group members presented within the group

Group members often commented, either during or at completion of group sessions, how helpful they felt the group had been and frequently commented that they felt better. Group members found that check-ins and check-outs were extremely helpful in addressing patients' immediate needs for help and decreasing patient distress. Positive feedback was given on postgroup surveys as well.

Nurses were educated to use deliberative nursing process within a nursing situation (involving the patient's behavior, the nurse's reaction, and the nurse's action) to identify with the patient what the meaning of the patient's behavior is, so that the patient's immediate need for help could be met and distress relieved. Involvement of the patient in discerning the meaning of his or her behavior was found to effectively promote a dynamic nurse–patient relationship. Validation with the patient that the need had been correctly identified and met resulted in positive patient outcomes (Potter et al., 2004).

Deliberative Nursing Process with Prospective Nursing Students Nursing Camp 2002 was a 2-week camp for 8th grade students that ran during the summer at Saint Anselm College in Manchester, New Hampshire. Nursing Camp 2002 was a partnership between the Manchester School-to-Careers Partnership, Saint Anselm College, Elliot Hospital, Hanover Hill Healthcare, New Hampshire Hospital (NHH), and Visiting Nurses Association Childcare Center. Sylvia Durette, camp director, and this writer introduced 27 students to Orlando's Deliberative Nursing Process as part of their overview of the nursing profession.

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Students also participated in an interactive experience related to Deliberative Nursing Process.

Deliberative Nursing Process in Clinical Practice Deliberative Nursing Process can be applied within a variety of practice settings. See Table 16.2 for examples of Deliberative Nursing Process in practice.

Table 16.2 Examples of Theory in Practice

Nursing staff at an extended care facility requested assistance from their nursing supervisor regarding problematic night behaviors of two older adult patients (Faust, 2002). The supervisor incorporated Deliberative Nursing Process to determine apparent unmet needs of the patients. She met with staff and formulated a plan of action. She assigned an additional nursing assistant to that wing, assumed responsibility for the two patients, observed the patients' behaviors, and validated her perceptions with these patients. Both patients demonstrated less distress and increased sleep during the nights.

Dye (2013) ascertains that Deliberative Nursing Process can be applied in multiple practice settings. Dye (2013) provides numerous examples to establish that one's perceptions, thoughts, and/or feelings can be used in situations to assess patient's needs. Dye (2013) further asserts

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that one needs to use one's perceptions, thoughts, and/or feelings to seek validation from the patient and use this validation to take further action. Dye (2013) concludes that when this is not done, assumptions often are made, which lead to poor patient outcomes. Dye (2013) also provides multiple examples to affirm that Deliberative Nursing Process can be applied to settings beyond nursing.

Bezanson (2002) proposed a theoretical application of Deliberative Nursing Process for an outpatient surgery center of an acute care, community-based hospital. Bezanson asserts that implementation of Deliberative Nursing Process could provide opportunities to improve nursing practice, increase patient satisfaction, and enhance staff satisfaction with their nurse–patient interactions. Bezanson also suggests that mechanisms of evaluation might include patient-focused satisfaction surveys, staff self-reports of satisfaction in practice, and improved patient outcomes.

Deliberative Nursing Process in Education Applications Potter and Moller (2016) apply the Deliberative Nursing Process in their textbook to assist nursing students in learning the deliberative process of communicating with patients. Throughout the textbook, a variety of case examples are employed to assist students in using their perceptions, thoughts, and feelings to validate patient needs with patients (See Using Middle Range Theory in Practice 16.1).

USING MIDDLE RANGE THEORY IN PRACTICE 16.1

Deliberative Nursing Process is being used in educational settings to assist nursing students to communicate effectively with patients to meet patient needs. Potter and Moller (2016) included examples of Orlando's Deliberative Nursing Process in their psychiatric mental health nursing textbook to enhance student nurse communication skills.

Source: Potter, M. L., & Moller, M. D. (2016). Psychiatric mental

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health nursing: From suffering to hope. Boston, MA: Pearson Education, Inc.

Problem Nursing students may have a difficult time communicating with

patients. They may be unsure of what to say or do to best help a patient in distress, especially in short interactions with patients.

Intervention Throughout the Potter & Moller textbook, case study inserts model

Orlando's Deliberative Nursing Process to help nursing students be more effective in communicating with patients. In each case study, the patient's behavior (actions and words) is shown. Following that are the nurse's perceptions, thoughts, and/or feelings of the patient behavior. Each case study then shows the nurse's exploration of their perceptions, thoughts, and/or feelings of the behavior, that is, what the nurse says to the patient. The nurse's perceptions, thoughts, and/or feelings of the patient's behavior are then validated to help the nurse best meet the patient's need for immediate help and relieve patient distress.

Deliberative Nursing Process in Measuring Nursing Outcomes The nursing executive leadership at NHH established Orlando's dynamic nursing process theory as a foundation for practice in 1996 and utilized Deliberative Nursing Process as a driving principle in the formation and functioning of a Nursing Practice Enhancement Project (NPEP) (Allen, Bockenhauer, Egan, & Kinnaird, 2006). The NPEP was instituted with the purpose of “redesign[ing] a model” to apply in psychiatric nursing care at NHH. The nursing leadership at NHH identified the interpersonal nurse– client professional relationship as key to healing and psychiatric care. In the process of developing the NPEP, Deliberative Nursing Process was instrumental in helping nurse staff to find a “common approach” to a broad range of clients; furthermore, affirmation of the nursing role as described in the Deliberative Nursing Process became “one of the cornerstones of empowered nursing practice” (Allen et al., 2006, p. 141). A Nursing Practice Outcomes Committee was formed to measure the effectiveness of

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the redesigned nursing model of psychiatric care at NHH and found that the revised model of care was effective in reducing the occurrence of seclusion–restraint, improving both patient satisfaction and nurses' job satisfaction (Allen et al., 2006).

Research Applications Deliberative Nursing Process has been categorized as a nursing process theory (Orlando, 1990), a prescriptive theory (Wooldridge, Skipper, & Leonard, 1968), and a reflective practice theory (Schmieding, 2002). The inductive, research-based approach Orlando used to develop Deliberative Nursing Process as a theory was unique. Meleis (1997, p. 348) points out that Orlando used field methodology before it became widely accepted in research use.

Diverse Range of Research Applications Orlando's theory has been widely used as a framework for numerous studies in a variety of settings. Areas studied encompass nursing theory, practice, education, and administration. Both qualitative and quantitative approaches have been employed.

Deliberative Nursing Process has been applied in theory analysis (Alligood & Choi, 1998; Andrews, 1989; Walker & Avant, 1995). A number of patient outcomes have been studied using Deliberative Nursing Process including, but not limited to pain (Barron, 1966; Bochnak, 1963; Bochnak et al., 1962), postoperative recovery (Eisler, Wolfer, & Diers, 1972), blood pressure and pulse rates (Mertz, 1963), vomiting (Dumas & Leonard, 1963), and levels of distress (Potter & Bockenhauer, 2000). Additional areas explored using Deliberative Nursing Process include spousal grieving (Dracup & Breu, 1978), breastfeeding (Clausen, 1983), and cancer (Reid-Ponte, 1988). Nursing education (Abdoli & Safavi, 2010; Haggerty, 1987; Orlando, 1972) and nursing administration (Schmieding, 1984, 1992) also have been examined using the Deliberative Nursing Process. (For additional studies using Deliberative Nursing Process, refer to the Bibliography.)

Potter, Vitale-Nolen, and Dawson (2005) designed a study to determine if implementation of a safety agreement tool made a difference

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in the rate of patient self-harm incidents and in nurses' feeling more comfortable interacting with patients at risk for self-harm. A safety agreement was designed to assist nurses in incorporating Deliberative Nursing Process when interacting with patients at risk for self-harm (see Using Middle Range Theory in Research 16.2).

USING MIDDLE RANGE THEORY IN RESEARCH 16.2

Source: Potter, M. L., Vitale-Nolen, R., & Dawson, A. M. (2005). Implementation of safety agreements in an acute psychiatric facility. Journal of the American Psychiatric Association, 11(3), 144–155.

Nurses at New Hampshire Hospital (NHH), a university-affiliated, state psychiatric facility, were interested in determining if implementation of safety agreements would affect patient outcomes and nursing comfort levels when working with patients at risk for self-harm (Potter et al., 2005). Registered nurses (RNs) serving on a Continuous Quality Improvement (CQI) Committee had examined the use of safety contracts by nurses at the facility and developed a safety agreement tool that they thought would facilitate incorporating Orlando's Deliberative Nursing Process when assessing patients at risk for self-harm.

Validity of safety contracts in general has not been tested. Confusion and controversy exist in relation to the definition and the use of safety contracts with patients who are suicidal (Potter & Dawson, 2001). It is suspected that this confusion and controversy lead to a discomfort and a lack of direction when nurses “contract” with patients for safety.

It has been demonstrated by nurses at NHH that Deliberative Nursing Process can make a difference in patient outcomes (Potter & Bockenhauer, 2000).

Purpose The purpose of the study was to determine if a more standardized process, using Orlando's Deliberative Nursing Process to enhance communication, would promote patients' agreeing to be safe and, in turn, decrease the rate of self-harm incidents and increase RNs' comfort

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levels when working with patients at risk for self-harm.

Research Design The researchers used quasi-experimental methods.

Participants There were 44 RNs who responded to the initial survey and 49 who responded to the follow-up survey.

Data Collection Safety agreements were implemented as the standard of care on all units in acute psychiatric services (APS). Incidents of self-harm were collected via the organizational-wide data collection system pre- and postimplementation. Instruction for RNs in the use of safety agreements occurred the month before implementation of safety agreements. RNs already used Deliberative Nursing Process as a framework for nursing care. The RNs were invited to complete two different surveys on the use of safety agreement—first was offered at the end of the first 3-month period and the second was offered at the end of 12 months. There were two convenience sample databases: (a) anonymous lists of self-harm incidents (only chart numbers used, not patient names) and (b) all RNs who performed direct patient care.

The investigators used t-tests to detect differences in pre- and postintervention outcomes and Stat Pac Gold computer software to analyze data for statistical differences.

Findings The mean rate of self-harming incidents did not change significantly pre- and postimplementation of safety agreements. RNs were equally divided in relation to thinking safety agreements enhanced or did not enhance nurse–patient interactions. However, RNs did report improvement in the following areas related to use of safety agreements: patient responsibility, nurse contact with patients, guidance for safety concerns, discussions with patients related to safety, and time guidelines around issues of safety.

Deliberative Nursing Process can be used as a framework to design research in various settings and to examine specific patient outcomes. The

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study illustrated in Using Middle Range Theory in Research 16.3 demonstrates patient outcomes related to reduction in levels of distress when Deliberative Nursing Process was implemented in an acute care psychiatric hospital setting.

USING MIDDLE RANGE THEORY IN RESEARCH 16.3

Source: Potter, M. L., & Bockenhauer, B. J. (2000). Implementing Orlando's nursing theory: A pilot study. Journal of Psychosocial Nursing and Mental Health Services, 38, 14–21.

Purpose The study's purpose was to determine if within a large, university- affiliated state psychiatric facility implementation of Orlando's nursing theory-based practice (Deliberative Nursing Practice) made a difference in patient outcomes when compared with patient outcomes resulting from interventions using nonspecified nursing practice.

Research Design This was a quasi-experimental pilot study.

Participants Two inpatient units were selected that matched most closely in staffing patterns, patient census, and acuity levels. Ten RNs participated—six in the experimental group and four in the control group. The experimental and control groups of RNs had no significant differences in their demographic composition. Thirty patients were involved in the study— 19 in the experimental group and 11 in the control group. Patient experimental and control groups were statistically similar.

Data Collection The RNs were educated in use of the Bockenhauer-Potter Scale of Immediate Distress (BPSID), a five-point Likert-scaled instrument that quantifies the level of patient-demonstrated distress. The BPSID was developed to control for subjectivity when assessing patients' levels of distress. The two investigators, a consultant in Orlando's theory, and

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three hospital RN nurse specialists reviewed and enhanced reference points on the scale. Videotaped simulated interactions helped nurses to learn how to use the BPSID, thus increasing interrater reliability. RNs in the experimental group received instruction in Deliberative Nursing Process. Data collection took place over a 12-week time frame. Distress levels of patients were measured before and after RN interventions.

Findings A greater reduction (p = 0.04) in patients' levels of distress occurred in the group in which RNs used the Deliberative Nursing Process. Interestingly, RNs who used the Deliberative Nursing Process reported that having a “road map” helped them feel more effective in their nursing interventions. Further research is suggested to control the possible “halo effect” of additional attention provided to the experimental group of RNs via weekly support and education and to obtain verbal feedback from patients who experience nursing interventions that incorporate Deliberative Nursing Process.

Olson and Hanchett (1997) carried out a study examining Orlando's assertion that relationships exist between nurse-expressed empathy and several patient outcomes. They used a descriptive, correlational format, described in Using Middle Range Theory in Research 16.4.

USING MIDDLE RANGE THEORY IN RESEARCH 16.4

Source: Olson, J., & Hanchett, E. (1997). Nurse-expressed empathy, patient outcomes, and development of a middle-range theory. Image: Journal of Nursing Scholarship, 29, 71–76.

Purpose The purpose of the study was to explore the relationships between nurse-expressed empathy and two patient outcomes (patient-perceived empathy and patient distress). The hypotheses were as follows: (a) a negative relationship will exist between measures of nurse-expressed empathy and measures of patient distress; (b) a positive relationship will

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exist between measures of nurse-expressed empathy and patient- perceived empathy; and (c) a negative relationship will exist between patient-perceived empathy and measures of patient distress.

Research Design A descriptive, correlational research design was used to test the hypotheses.

Participants One hundred and forty subjects comprised the sample. Seventy staff RNs were selected from a pool of 50% of all eligible nurses who were invited. Seventy patients for whom the nurses cared during a day shift were randomly selected to participate.

Data Collection Nurse participants completed the Staff–Patient Interaction Response Scale (SPIRS) and the Behavioral Test of Interpersonal Skills (BTIS). Both measure nurse-expressed empathy. Patient participants completed the Empathy Subscale of the Barrett-Lennard Relationship Inventory (BLRI) to determine patient-perceived empathy measures; their patient distress scores were measured using the Profile of Mood States (POMS) and the Multiple Affect Adjective Checklist (MAACL).

Testing of hypothesis was as follows: (a) hypotheses one and three were tested together by means of one canonical correlation and (b) hypothesis three was tested by means of multiple regression analysis.

Results All three hypotheses received statistically significant support with the BTIS measurement. A fuller description of methodology and findings are recorded in a report by Olson (1995). This study supported Orlando's (1961, 1972) assertion that relationships exist between accurate perceptions of patients' needs (nurse-expressed empathy and patient-expressed empathy) and patient distress.

Delivering Culturally Competent Care Recently, Deliberative Nursing Process was used in the formation and implementation of the Influenza Initiative in New York City—a

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collaborative nursing effort to meet linguistic needs and provide culturally competent care. This project involved delivering education and immunizations for influenza prevention to an urban population (Aponte, 2009). In this program, bilingual nursing students were paired with nursing providers from a home health care agency to translate for non–English- speaking Spanish, Chinese, Russian, and Ukrainian residents participating in the Influenza Initiative in Fall 2006 and 2007. With Deliberative Nursing Process as a nursing framework for providing care, nursing students were able to confirm and validate clients' needs, ensure accurate understanding of information, confirm consent for treatment, and direct RNs to administer immunizations in a safe and culturally competent manner (Aponte, 2009).

Ethical Values in Caring for Older Adults In a study by Jonasson (2009), the dynamic nurse–patient relationship is presented as crucial to the process of determining the ethical care of older adults. In her study of nurse–patient interactions between nurses, older adults, and their next of kin, Jonasson points to the processes of validation and evaluation as crucial to providing true benefit to the patient and their family. Through observation and interview data collection, she found that body language, elements of respect, and behavior elements of the initial approach of a nurse with an older adult client are crucial in developing a therapeutic nursing relationship. Moreover, the patient and next of kin's perceptions of the nurses' availability and approachability led to improved patient and family feelings of being valued and acknowledged. Jonasson challenges nurses to recognize the extent to which their approach to patients impacts patients' feelings and outcomes, as dependent upon nurse “attitude and actions” (Jonasson, 2009, p. 26).

Nursing Informatics In a paper regarding nursing process theory and the development of nursing information systems to improve care delivery in the future, Alexander (2007) highlights the role of Orlando's prescribed elements of nursing process: observations, actions, reporting, and recording. In particular, Alexander proposes a nursing informatics model, called the nurse–patient trajectory framework. This trajectory incorporates both patient and provider inputs to coordinate patient care and nursing process

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elements with human–computer interaction to direct the overall plan of care (Alexander, 2007). In comparison to other models of nursing informatics to determine the plan of care, this model would uniquely involve patient input. This would ensure inclusion of validation and evaluation of the client's needs and perceived sources of distress and comfort, rather than promoting an automatic nursing process through technology-guided information processing.

Instruments Used in Empirical Testing There are no set means or tools to measure Deliberative Nursing Process. This is indicative of the nature of the theory because Orlando emphasized that Deliberative Nursing Process involves a nursing situation in which the uniqueness of the nurse is brought to the experience to meet the immediate needs for help, as expressed by the patient, explored by the nurse and the patient, and validated by the nurse with the patient. Each circumstance or nursing situation will be unique and different, because each nurse perceives, feels, and thinks differently than any other nurse entering the same nursing situation.

Different tools have been developed and/or used to measure different aspects of Deliberative Nursing Process. These tools facilitate examination of such factors as patient outcomes, nursing process, nurse empathy, and patient-perceived empathy. The instruments have been developed and/or used to test Deliberative Nursing Process qualitatively and quantitatively. Instruments used in different studies explore different aspects of the Deliberative Nursing Process, such as theory description and analysis, use in research, use in clinical practice, and use in administrative practice.

Much of the testing done with Deliberative Nursing Process involves questionnaires and surveys. Examples of tools that have been used for studies involving Orlando's Deliberative Nursing Process are listed in Table 16.3.

Table 16.3 Deliberative Nursing Process Tools

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Safety Agreement Instrument One instrument used in the study of Deliberative Nursing Process has been the safety agreement. The safety agreement instrument, developed by nurses at NHH, was designed to measure patients' risk for self-harm and willingness and the ability to agree to remain safe (see Table 16.3). Most of the agreements are designed in Likert-style format. A question related to a patient's perceived ability to remain safe requires a “yes” or “no” response. In addition, a question seeking to determine how the patient and RN might work together to manage the current risk for self-harm elicits a response from a number of given choices with an “other” option included. The intent of the safety agreement is to assist the RN in a deliberative process of determining with the patient the patient'srisk for self-harm.

A safety agreement was implemented by Potter et al. (2005) at NHH; the agreement was used in a convenience sample, with all patients admitted or considered at risk for self-harm. Patients were asked to self- rate the following areas with the RN: (a) their current harm level, (b) the likelihood of their acting on their thoughts of self-harm, (c) their thoughts about managing the risk with the RN, (d) their willingness to enter an agreement for safety with the RN, and (e) their thoughts about how long they think they can remain safe.

In the context of this study, RNs were given the Registered Nurses

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Evaluation Survey, which also was in Likert-type format, except one question. RNs were asked to evaluate (a) the number of times they used the safety agreement in a 3-month period, (b) if the safety agreement assisted them in feeling more comfortable while helping patients at risk for self-harm, (c) if they thought self-harming incidents decreased since implementation of safety agreements, and (d) if they had any other comments to share related to use of safety agreements. With the use of safety agreements, RNs reported improvement in patient responsibility, nurse contact with patients, guidance for safety concerns, discussions with patients related to safety, and time guidelines around issues of safety. Using Middle Range Theory in Research 16.2 describes the design and outcome of this research study implementing safety agreements at NHH (Potter et al., 2005).

Pain and Distress Instrument A study of nursing caregivers (RNs and nursing students) revealed associations between nursing assessments of patient distress according to particular patient and caregiver characteristics (Hall-Lord & Larsson, 2006). The investigators measured patients' pain and distress with a 13- item pain and distress questionnaire to evaluate sensory, emotional, and existential dimensions of distress (see Table 16.3). Caregiver characteristics were assessed using the sense of coherence (SOC) scale, five-factor personality inventory (FFPI), and their degree of experience in nursing. When given the same patient scenarios, Hall-Lord and Larsson (2006) refer to Orlando's assertion that nurses' personality factors contribute to their automatic responses, which is supported in their research. They report that nursing experience and personality factors apparently impacted their assessments and ability to empathize with patients in distress, along with factors of patient age and illness type and severity. Their study supports the need for more reliable pain and distress instruments, and improved self-awareness among nurses, to diminish biases and variability in assessments of patient comfort.

Conclusion Ida Jean Orlando developed Deliberative Nursing Process theory at a time

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of great need and growth within the nursing profession, and as demonstrated in the recent examples, her work continues to be relevant to improving patient outcomes and advancing the nursing profession. Soon after Orlando's original publication, Gowan and Morris (1964) speculated that the nursing shortage of that era and the increased expectations upon nurses led to nurses spending more time designing care than providing care. Results from their study indicated that patients experienced undue delays in receiving care and withheld requests that involved their well- being due to patient perceptions that the nurses were too busy, would disapprove, would not like to be interrupted, or would think the request was not helpful to the patient. Might this same scenario be repeating itself today?

In 1990, the National League for Nursing honored Orlando by reprinting The Dynamic Nurse–Patient Relationship. Orlando noted in the Preface to that edition that interest in the United States using her theory had waned (Orlando, 1990, p. viii). Interest and use of the theory may have subsided temporarily, but it never ceased. As noted by Orlando herself, her work has been published in five foreign countries, and there have been numerous publications in recent years related to Deliberative Nursing Process (Potter & Bockenhauer, 2000; Potter & Dawson, 2001; Potter & Tinker, 2000; Rosenthal, 1996; Schmieding, 1993b, 1999, 2002). Many changes have occurred in nursing. However, the essence of nursing, described so simply yet eloquently by Orlando, has not changed—namely, that the nurse–patient relationship involves a dynamic and unique process that evolves between nurse and patient when approached deliberatively and validated with the patient on an ongoing basis.

Deliberative Nursing Process is a nursing theory for all times. The use of Deliberative Nursing Process helps nurses maintain a patient-centered approach when providing nursing care amidst additional and varied expectations of the nurse. Orlando has kept the message of deliberative nursing process clear throughout the years: “It is the nurse's direct responsibility to see to it that the patient's needs for help are met, either directly by her own activity or indirectly by calling in the help of others” (Orlando, 1961, p. 29). Adopting such a clear function promotes effective and efficient nursing practice as has been demonstrated through empirical studies on Deliberative Nursing Process for more than 40 years.

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Summary The Deliberative Nursing Process was developed by Ida Orlando based upon her observations of many nurse–patient interactions. Deliberative Nursing Process is classified as a middle range theory; it is both a simple and complex theory. Deliberative Nursing Process (DNP) is relevant for all times, places, and persons and can be applied in education, practice, and research. Orlando asserts that it is the nurse's responsibility, directly or indirectly, to see that patient needs are met. Nurses should never assume they know what the patient's needs are. Nurse–patient interactions are unique for that nurse and patient in that moment in time. Deliberative Nursing Process involves nurses using their perceptions, thoughts, and feelings related to the patient's behavior to identify a patient's need for immediate help. Nurses need to validate with patients that their needs have been identified and met. According to Orlando, automatic nursing process is “bad” or ineffective nursing, and deliberative nursing process is “good” or effective nursing.

Critical Thinking Exercises

1. Scenario: Upon entering a patient's room on the medical unit, the nurse notices the patient's right hand over her heart. The patient has her head down and is sobbing. Give examples of how you, as the nurse, might share each of the following: a. Your perceptions b. Your thoughts c. Your feelings

2. What is the function of “validation” in Deliberative Nursing Process?

3. State three ways using Deliberative Nursing Process is more beneficial in the nurse–patient relationship than using automatic nursing process.

4. Compare and contrast the concept and definition of comfort in

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Deliberative Nursing Process with the concept of comfort according to other nursing theorists, such as Kolcaba or Leininger.

5. Discuss if/how Deliberative Nursing Process could benefit nursing practice in an intensive care setting, even if patients were unconscious or unable to communicate verbally.

6. Consider Orlando's distinction between the roles of “nursing” and “doctoring” in patient care. Discuss how the same roles do/do not apply to physicians and nurses today.

7. Do you agree with Orlando's assertion that nursing is either “good” or “bad”? If so, why? If not, how would you define excellence in nursing?

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of deliberative nursing process.

Acknowledgments Much appreciation is expressed to Mimi Dye, MSN, ARNP, who completed the critique on deliberative nursing process in the Appendix A and studied deliberative nursing process as a student with the theorist, Ida J. Orlando, MS, RN; Joy L. Potter, who served as research assistant in the second edition; Dorothy Y. Kameoka, MLS, MSW, RN, who sought out materials for the first and second editions; Rebecca E. Andersen, RN, MSN, who served as research assistant in the third edition; and Sarah Ames, RN, MS, who served as research assistant on this fourth edition— thank you and may you enjoy the deep satisfaction nursing offers.

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17 Resilience Joan E. Haase and Celeste R. Phillips

Definition of Key Terms

Boundaries of resilience The contextual influences, dimensions, and assumptions that are considered in determining the attributes of resilience

Meaning-based models Explanatory models focused on the patterns and experiences of illness from a subjective and holistic perspective

Person-focused resilience research Research to identify the patterns of variables in which resilience naturally occurs and then examining what might contribute to these outcomes, or using cutoff scores on selected variables to categorize adversity subgroups and then examining outcomes in these groups

Positive health research Efforts to gain understanding of ways individuals sustain or regain optimal health

Protective factors The individual, family, social, or other contextual factors that enhance resilience processes and outcomes

Quality of life A sense of well-being

Resilience General definition: positive adjustment in the face of adversity. Context-derived definition: the process of identifying or developing resources and strengths to flexibly manage stressors to gain a positive outcome, a sense of confidence/mastery, self-

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transcendence, and self-esteem

Risk factors The individual, family, social, or other contextual factors that impede development of resilience processes and outcomes

Strengths-based research Research that focuses on positive health concepts (e.g., hope, optimism, resilience, spirituality) rather than on risks within the individual, family, or community

Mixed methods research Use of a combination of quantitative and qualitative research approaches either sequentially or simultaneously to answer research questions and to refine, evaluate, and/or extend theory

Variable-focused approaches Use of multivariate statistics to test for linkages to resilience among measures of adversity, outcomes, and environmental or individual qualities that may protect from, or compensate for, negative consequences

Introduction Researchers have long sought answers to questions about the psychosocial impact of illness, especially chronic conditions. Much of this research was guided by pathology and deficit-based models that examined risks, adjustment problems, and developmental delays (Hymovich & Roehnert, 1989). In the 1970s, researchers in nursing and other disciplines began to recognize the importance of understanding why some individuals do well in the face of adversity (Antonovsky, 1979; Masten, 2007). Theories such as resilience (Rutter, 1979, 1987), hardiness (Kobasa, 1982), self-efficacy, and learned resourcefulness (Bandura, 1977; Rosenbaum, 1983) were developed to explain positive adjustment to illness, based on the belief that such theories may yield information about effective interventions (Forsyth, Delaney, & Gresham, 1984; Garmezy, 1991; Kadner, 1989; Sinnema, 1991). In 2001, the Committee on Future Direction for Behavioral and Social Sciences highlighted the significance of behavioral and psychosocial processes in disease etiology, well-being, and health promotion (Singer & Ryff, 2001). The committee identified resilience as a research priority for the National Institutes of Health and recommended

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increased study of the protective factors that are correlates of resilience. These factors included optimism, meaning and purpose, social and emotional support, and related neurobiological mechanisms that promote recovery and increased survival rates (Singer & Ryff, 2001). The rapidly increasing number of theory and research reports in the literature indicate strong uptake of the recommendations. Nurses also recognize the importance of positive health concepts and are increasingly seeing an understanding of resilience as potentially useful to (a) guide development of interventions to enhance positive outcomes, (b) improve outcomes for at-risk populations, (c) prevent poor outcomes, and (d) influence public policy related to individuals, families, and communities.

Historical Background and Current Perspectives Historically, resilience was consistently and broadly defined as a phenomenon of positive adjustment in the face of adversity. Resilience was first studied in children and adolescents and was characterized by attributes usually identified as positive in the presence of adversity. After describing children who thrived despite adversity, subsequent studies were directed to understanding attributes to explain individual differences in response to adversity. Examples of such individual protective factors found in early research on resilience include the following:

Competence (Garmezy, Masten, & Tellegen, 1984; Rutter, 1979) Self-esteem (Garmezy, 1981) Superior coping (Garmezy, 1991; Murphy & Moriarty, 1976) Advanced self-help, communication, and problem-solving skills (Garmezy, 1981; Hauser, Vieyra, Jacobson, & Wertlieb, 1985) Tendency to perceive experiences constructively (Werner & Smith, 1982) Ability to use spirituality to maintain a positive vision of a meaningful life (Rutter, 1979; Wells & Schwebel, 1987)

Resilience researchers gradually began to recognize family and social protective factors as influencing resilience development (Rutter, 1987). This expanded view of protective factors, studied as processes occurring

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over time, included research on childhood exposure to adverse conditions of socioeconomic adversity (Rutter, 1979), abuse (Henry, 2001), urban poverty and community violence (Luthar, Cicchetti, & Becker, 2000), and chronic illness (Wells & Schwebel, 1987). In addition to continuing to describe protective factors, researchers sought to understand the underlying mechanisms or processes of interaction between risk and protective factors and their influence on resilience outcomes (Luthar et al., 2000).

Since 2000, when researchers increasingly viewed resilience from a multilevel—society to cell— perspective and when multidimensional analyses strategies (e.g., latent variable structural equation modeling) improved, research on resilience has gained much attention and advanced understanding significantly (Cicchetti, 2011; Cicchetti & Blender, 2006; Masten, 2007). The recognition that resilience occurs at multiple levels fostered more interdisciplinary research to simultaneously examine psychological, biological, and environmental–contextual processes (Cicchetti & Blender, 2006). Theoretical models were also developed and tested (Mullins et al., 2015).

Definition of Resilience and Concepts There is now widespread agreement that resilience is a complex, multidimensional construct. Largely because of the complexity of the construct, there is a lack of consensus regarding (a) terminology, (b) characteristics, and (c) boundaries of resilience. The following sections examine the various perspectives within these three areas from both the general and the nursing literature.

Perspectives on Resilience

Terminology and Attributes of Resilience To adequately define a construct, terminology needs to be consistently

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used. In the case of resilience, even the labels for the construct are inconsistently used (e.g., resilience, resiliency, and ego-resilience). The term resilience, rather than resiliency, is favored to describe positive adjustment in the face of adversity (Luthar et al., 2000). “Resiliency” is not recommended because the word implies a personality trait that is difficult to alter, much like hardiness. The term ego-resilience characterizes resilience as a distinct personality trait. Hence, ego-resilience decreases the options for intervention and increases the danger of labeling individuals as innately “inadequate.”

There are two generally recognized essential attributes of resilience present in most definitions. These are the presence of (a) “good” or positive adaptation that (b) occurs in spite of adversity, which is associated with adjustment difficulties (Fletcher & Sarkar, 2013).

Good Outcomes. “Good” or positive outcomes are not consistently theoretically or operationally defined in the literature. Debate centers on what constitutes “good” outcomes and who decides. Additional questions include whether external criteria (e.g., academic achievement), intrapersonal characteristics (e.g., sense of well-being, self-esteem), or a combination of both are defining characteristics of positive outcomes (Masten, 2001).

Paradigmatic approaches have also contributed to differences in ways positive outcomes are defined. A pathology-based worldview often defines positive outcomes as the absence of psychopathology or low levels of symptoms or impairments (Masten & Coatsworth, 1998). Developmental and life span perspectives usually define positive outcomes as those that meet or exceed expectations. The emerging perspective emphasizes dynamic ecosystems influenced by complex, ever-changing, and interacting forces (Richardson, 2002; Waller, 2001) and by the notion that resilience is possibly a common human characteristic—“ordinary magic” (Masten, 2001).

Adverse Conditions. The theoretical and operational definitions of “adverse conditions” are also inconsistent in the literature. Frequently, definitions imply threats or risk factors that occur in contexts such as war, illness, community deficits, or family adversity. Beyond the requirement that such factors negatively

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affect resilience outcomes, there is no agreement regarding how such risks should be operationalized. Options include (a) current or past occurrence, (b) predictors of poor outcomes or status (moderating) variables such as low socioeconomic status, or (c) single-exposure variables or cumulative combinations of factors. Adding to the inconsistency of defining characteristics, risk factors can be continuous bipolar variables classified as either less or more aversive (e.g., mild to severe symptoms) or as negative to positive assets (e.g., low to high economic status and negative to positive coping) (Masten, 2001). In general, much research indicates that risk factors, however operationalized, often co-occur (Masten, 2001). Adding to the confusion, the term adversity is value-laden and implies events that are exclusively negative when, indeed, there are also positive events that may have potentially poor outcomes, such as job promotion or marriage (Fletcher & Sarkar, 2013).

Boundaries of Resilience Boundaries are the contextual influences (i.e., conditions under which resilience exists/varies/disappears), dimensions (e.g., objective/subjective and physiological/psychological), and underlying assumptions (e.g., growth vs. stability and state vs. trait) that are considered in determining the attributes of resilience. Some boundaries of resilience that need careful explication in theory and research include (a) state/trait/process/outcome, (b) psychological/physiological, (c) individual/aggregate, and (d) objective/subjective perspective. Within each of these boundaries, the cross-cultural implications also need thoughtful examination and further research. Resilience may also vary in relation to contextual severity, ranging from everyday hassles to extensively stressful experiences (e.g., loss of a child) (Fletcher & Sarkar, 2013).

Trait/State/Process/Outcome. Although the definition of resilience as the presence of “good” outcomes that occur in the face of adverse conditions implies a process, there is no consensus on the issue of resilience as trait, state, process, or outcome. Again, the confusion is exacerbated by inconsistent terminology and the inability to draw conclusions of causality (Pettit, 2000). For example, as indicated above, the term ego-resiliency is frequently used interchangeably with resilience, but the former refers to a set of personal characteristics

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(traits) that may or may not be specifically linked to adversity (Luthar et al., 2000). In addition, terms such as resilient children cause confusion. Although this term implies that resilience is a trait, it is used most often in conjunction with the two coexisting conditions of adversity and positive adaptation, with adaptation usually conceptualized as a process. When researchers do not clearly specify a model of resilience that stipulates how the underlying mechanisms in a resilience process may result in specific resilience outcomes, even terms such as outcome and process contribute to the confusion. Researchers should clearly specify the context in which resilience outcomes apply and delineate the outcomes by using terms such as emotional resilience, behavioral resilience, or educational resilience. It would also be helpful, through staged model specification, to distinguish proximal resilience outcomes, such as self-transcendence and confidence/mastery, from more distal outcomes, such as quality of life, which result from the resilience process and resilience outcomes.

Psychological/Physiological. Psychological concepts associated with resilience have been more widely studied than physiological concepts. Concepts such as self-esteem, self- perception, personality, temperament, intellect, coping, and problem- solving skills are just a few of the psychological concepts that have been studied as correlates of resilience. With advances in statistical modeling and computer science, it is now possible to examine resilience on multiple levels, such as gene–environment interactions (Masten, 2007). Singer and Ryff (2001) identified several positive physiological mechanisms, including those that involve the hypothalamic–pituitary–adrenal (HPA) axis and the autonomic nervous system, which may be linked to positive health and resilience. They further argue for integrative levels of analysis that include the physiological, behavioral, environmental, and psychosocial systems to better understand how each contributes individually and interactively to resilience. Curtis and Cicchetti (2003) provided a thoughtful perspective of the theoretical and methodological considerations for examining the biological contributors to resilience. Specifically, they discuss a transactional organizational theoretical perspective as a framework for including biological considerations. The recent advances in neurosciences and related technology, such as functional magnetic resonance imaging (fMRI), are highly promising avenues of investigation.

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Individual/Aggregate. Resilience is most often studied in individuals, but to avoid confusion about yet another boundary, it is important for researchers to specify levels of analysis. For example, Haase's Resilience in Illness Model (RIM) identifies family environment as a protective factor (composed of family, adaptability, cohesion, communication, and perceived strengths) that influences the individual child, adolescent, and young adult resilience outcomes (Haase et al., 2014). Other models of resilience for children with chronic illness characterize the child and family's adjustment as a transactional process occurring over time (Mullins et al., 2015). The Social Ecological Model (Kazak, 2006; Kazak, Segal-Andrews, & Johnson, 1995) is one example that identifies many systems—child, family, social group, school, community, and culture—all interacting to influence the child and family outcomes. In nursing, the Children's Oncology Group adapted Haase's RIM as the guiding framework for research proposed by the Nursing Discipline Committee; they expanded it to include family and culture, as well as the individual and family ages, development levels, and genetic characteristics (Kelly, Hooke, Ruccione, Landier, & Haase, 2014).

Objective/Subjective. The issue of which perspective—objective or subjective—to value is another area of inconsistency. For example, in a qualitative study of homeless adolescents, the sample included adolescents who considered themselves resilient (Hunter & Chandler, 1999). According to the adolescents, being resilient was “surviving.” The self-assigned attribute of resilience by the adolescents was quite different from the characteristics of resilience found in other literature. Hunter and Chandler's research indicated that resilience in homeless adolescents may be a “process of defense using such tactics as insulation, isolation, disconnecting, denial, and aggression or a process of survival by using responses such as violence” (p. 246). These findings indicate that self-attributed resilience in homeless adolescents lacks a positive or good outcome, a key characteristic of resilience in the literature. These findings were further supported in a subsequent study by Hunter (2001) that examined cross- cultural perspectives of resilience in adolescents from New England and Ghana, wherein all the adolescents viewed themselves as resilient, regardless of age, gender, culture, or socioeconomic status. Yet, depending on the presence or absence of consistent, loving, caring, and mentoring

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adults, there were qualitative differences in how the adolescents overcame adversities. Hunter classified these as two different “forms of resilience”: self-protective survival resilience or connected resilience.

Hunter and Chandler's findings illustrate how, if the objective and subjective dimensions of resilience are not carefully delineated, much of what determines the process and outcomes of resilience will be difficult to ascertain. For example, the cognitive appraisal of the adversity, the actions that are taken to deal with the adversity, and subsequent evaluation of how one is dealing with the adversity can all influence how resilience as a process proceeds (Fine, 1991). Further, if the objective and subjective appraisal, actions, and evaluation differ, then evaluation of outcomes and development of interventions will be more complex.

One potentially helpful way to delineate the objective/subjective dimensions of resilience is to consider whether resilience may be interpersonally assigned to an individual, much like courage is interpersonally assigned (Haase, 1987). Research indicates that individuals usually do not attribute courage to themselves, unless someone else initially indicates that their behavior could be interpreted as courageous (Haase, 1987). Likewise, it is possible that persons who have resilience require time to reflect on the meaning of their actions. That is, resilience may occur through a process that includes deriving meaning from the experience through interaction with others (Haase, Heiney, Ruccione, & Stutzer, 1999). After interviews were conducted, Hunter and Chandler's findings supported this perspective in that the adolescents' resilience scores increased from baseline measures (Hunter, 2001). A second consideration regarding the subjective perspective is the social desirability of being labeled “resilient.” It is possible that a label of being resilient parallels a label such as “honest” in that, when asked, one is not likely to readily deny having such a characteristic.

Cross-cultural Considerations Related to Boundaries In the midst of adversity, individuals are especially likely to return to cultural tradition to seek solutions (Hwang, 2006, p. 90). Hence, a full understanding of resilience needs to include cultural considerations. Few studies have explicitly examined the cultural boundaries of resilience, and resilience models need to be carefully evaluated cross-culturally prior to use. Following are two examples of potential differences in factors influencing resilience between Eastern and Western culture.

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In Western society, interpersonal interactions hold an assumption of respect for the principles of egalitarianism and independence (Triandis, Bontempo, Villareal, Asai, & Lucca, 1988). Thus, interpersonal relationships are based on a decisional choice. In Chinese culture, interpersonal relationships are composed of horizontal and vertical relationships. Horizontal relationships are constructed according to intimacy/distance, and vertical relationships are built according to superiority/inferiority (Hwang, 1997). Horizontal relationship indicates interaction within equal family or social positions, such as sibling or peer relationships. Vertical relationship means interaction among hierarchal family or social positions, such as child–parent or student–teacher relationships. The vertical relationship is less emphasized in Western society.

Since sense of self is also culturally different in Western and Chinese societies, how sense of self and interpersonal relationships work to foster resilience is also likely to be different. In Western society, the presentation of self is based on one's interpretation of interactions in specific social situations (Charon, 1998; Mead, 1952). In contrast, in Chinese society, the self is defined not by any situational interpretation but by person-in- relation status, which is called the “relational self” (Ho, Chen, & Chiu, 1991). In Chinese society, based on relational self, personal coping strategies, purpose in life, and interpersonal interactions may be more driven by status concerns in social relationships than in Western cultures.

In a comparison of Haase's RIM with qualitative findings from interviews with Taiwanese adolescent survivors of brain cancer, data indicated that fatalistic coping, a risk factor component of defensive coping in Haase's RIM (i.e., avoidant, fatalistic), may have a positive influence on survivorship in Taiwan (Chen, Chen, & Haase, 2007; Chen, Chen, & Wong, 2014). The adolescents used fatalistic coping, accepting that there was nothing one could do but accept the cancer and late effects based on tenets of one's sense of relational self that individuals have greater obligations to family, including those who have died, than to “small self” (personal self). In a quantitative study with the same population, findings indicate that adolescent survivors of brain cancer have greater problems than do well adolescents. In the Chinese culture, family or community protective factors may have greater influence as pathways to resilience, and individual protective factors, such as positive coping, may require alignment with family goals to actually serve a protective function. Clearly, a full understanding of resilience needs to include cultural

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considerations.

Resilience Perspectives in Nursing Not surprisingly, information in Table 17.1 indicates that there is no greater consensus on definitions, characteristics, or boundaries of resilience in the nursing literature than there is in the literature from other disciplines. The nursing literature on resilience parallels that of the general literature. Although nurses historically have focused more extensively on individual and family strengths than many disciplines, systematic study of resilience by nurses only began in the mid- to late 1980s. A major contribution to understanding resilience from the nursing literature is the focus on resilience in the context of health as well as a more recent focus on understanding resilience in nurses. Articles included in Table 17.1 provide a representative sample of both theoretical and empirical efforts to understand resilience by nurses, including varied populations and approaches to knowledge development.

Table 17.1 Nursing Literature on Resilience

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Terminology and Attributes of Resilience Most of the definitions in Table 17.1 include the characteristic of adversity. Some definitions specifically describe the adversity as stress, loss, or illness, whereas others use more global terms, such as “challenging life condition” (Drummond, Kysela, McDonald, & Query, 2002) or a “traumatic event” (Garcia-Dia et al., 2013). The “good” varies considerably in the definitions as well. Although several of the definitions

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use vague terminology, such as “maintenance of positive adjustment” (Drummond et al., 2002) or “spring back” (Mandleco & Peery, 2000), other definitions indicate the “good” reflected in processes of adaptation, positive health, and/or well-being (Ahern, 2006; Bekhet et al., 2012; Haase, 2004; Vinson, 2002). Only a few definitions of resilience provide clear descriptions of outcome variables associated with resilience.

Regarding the antecedents of resilience, there is some consensus that there are both risk and protective factors related to resilience. Risk factors are internal and external characteristics that hinder the individual's ability to cope or thrive during adversity. Protective factors “assist individuals to recover from and thrive despite adversity” (Grafton et al., 2010). However, there is the same inconsistency in the nursing literature as was found in the general resilience literature. Risk factors are believed to have the potential to hinder the development of protective factors identified as enhancing resilience. In some cases, both risk and protective factors were listed together. In these cases, one is forced to assume that either the risk factor is the absence of the protective factor identified or the resilience occurs on a continuum of risk to protection. Examples of the risk factors identified in the nursing literature include (a) presence of an adverse or traumatic event (Garcia-Dia et al., 2013), (b) symptom severity (Bekhet et al., 2012; Haase, 2004), (c) challenging workplaces (Hart, Brannan, & De Chesney, 2014), and (4) ongoing challenging life experiences such as aging (van Kessel, 2013). Few models specify the mechanisms by which the adversity itself may influence and even contribute to resilience.

The positive factors of resilience reflected in Table 17.1 are numerous. In many cases, where models were specified based on literature synthesis and/or qualitative research to develop a resilience model, the relationship to and among positive factors is clearly described. Taken as a whole, the literature set provides an emerging pattern that may help distinguish the attributes of resilience from the consequences (i.e., outcomes) of resilience. However, there appears to be some confusion on whether some of the concepts are actually attributes or consequences of resilience.

The most common attributes of resilience include the following:

Self-efficacy (Bekhet , Johnson, & Zauszniewski, 2012; Earvolino- Ramirez, 2007; Garcia-Dia et al., 2013; Gillespie et al., 2007; Grafton et al., 2010; Hart et al., 2014) Positive coping (Ahern, 2006; Drummond et al., 2002; Gillespie et al., 2007; Haase, 2014; Hart et al., 2014; Vinson, 2002)

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Hope (Gillespie et al., 2007; Haase, 2014; Hart et al., 2014) Spirituality/meaning and purpose (Grafton et al., 2010; Haase, 2014; van Kessel, 2013; Windle, 2011) Connectedness and social support (Ahern, 2006; Earvolino-Ramirez, 2007; Garcia-Dia et al., 2013) Positive family functioning (Drummond et al., 2002; Windle, 2011) Sense of humor (Ahern, 2006; Earvolino-Ramirez, 2007)

Consequences of resilience include the following:

Enhanced quality of life/well-being (Bekhet et al., 2012; Haase, 2014; Hart et al., 2014; Vinson, 2002) Positive adaptation (Drummond et al., 2002; Earvolino-Ramirez, 2007) Effective coping (Garcia-Dia et al., 2013; Gillespie et al., 2007; Grafton et al., 2010; Hart et al., 2014) Confidence/mastery (Earvolino-Ramirez, 2007; Haase, 2014)

Boundaries of Resilience With the exception of the psychological dimension that is identified by all authors, all the other boundaries of resilience, either explicit or implied, are inconsistent. There appears to be an emerging consensus that resilience is a dynamic process; however, some authors refer to it as a trait or state (Felten, 2000; Hunter, 2001; Mandleco & Peery, 2000). Most definitions imply that a change occurs, but there is inconsistency as to whether the resilience change is a return to a steady state or is part of a growth- producing process. Only one definition explicitly addresses a time frame (Hunter, 2001; Hunter & Chandler, 1999).

The existence of biological contributions to resilience remains strikingly missing from most of the nursing literature. This gap is reflective of the general state of the science on resilience on biological dimensions. This situation may improve with the advancing technologies that have resulted in a rapidly developing knowledge base in neuroscience (Curtis & Cicchetti, 2003). Mandleco and Peery (2000) are among the few who consider biological contributions to resilience. They identified four biological factors as possibly affecting resilience: general health, genetic predisposition, temperament, and gender. Research supports that children with resilience are usually quite healthy and have little hereditary or

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chronic illness. However, hypotheses about gender and temperament need further exploration. Evidence that temperament is a factor of resilience is derived from studies examining infant temperament; however, it is not clear that temperament is biologically based. Regarding gender, although males are more vulnerable to all risk factors, one cannot assume that more vulnerability equates to less resilience.

Resilience was most frequently studied as an individual dimension rather than as a family or community aggregate. In studies focused on individuals, the family or community variables were often included as protective factors that influence outcomes for the individual. In some ways, the state of knowledge on family resilience is further along than individually focused research in that the limited number of proposed models is more consistently being used and evaluated, and there is more consistency in the ways that family-level measures are used.

Nurses studying resilience seem to assume the importance of obtaining subjective indicators. These subjective indicators were obtained as narratives and as self-reported quantitative measures of resilience-related concepts. As indicated in section on “methods,” nurse researchers have also developed creative methods for obtaining the personal meanings associated with resilience. Ways of making sense of combined, simultaneous objective, physiological measures as they relate to subjective ratings is not addressed well in either the nursing or the general literature. Since nurses focus on both physiological and psychosocial aspects of health, it would seem logical that nurse researchers would be well positioned to provide leadership in this area.

Description of Resilience: the Theory There is agreement that models of resilience should include factors generally characterized as “protective.” In addition, “risk” factors are also generally identified as influencing resilience processes and outcomes. A major problem in developing theory about resilience is that these protective and risk factors frequently resemble “laundry lists.” That is, they lack an explicit description of underlying assumptions or an explicit theoretical framework that describes the mechanisms by which the protective and risk factors are linked to outcomes. Especially lacking are hypothesized paths or the magnitude of their influence on development of

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resilience. In addition, much confusion relates to whether these protective and risk factors are direct ameliorative effects or, rather, if they are interactive effects reserved for individuals who have a particular attribute and who have been relatively unaffected by high or low levels of adversity (Luthar & Cicchetti, 2000).

Important components that should be considered in all modeling efforts to understand and enhance resilience are contexts, including culture, psychological and physiological mediating units, and the patterns of mediators in relation to the context (Coyne & Downey, 1991; Freitas & Downey, 1998). Further, there is value in interventions that manipulate mediating variables such as coping and hope, which have been found to influence resilience outcomes (Singer & Ryff, 2001).

Masten (2001) provides a useful distinction between variable- and person-focused approaches to model development. In variable-focused approaches, multivariate statistics are used to test for linkages among measures of adversity, outcomes, and environmental or individual qualities that may protect or compensate for negative consequences. Models may examine direct, indirect, and interaction effects (Luthar et al., 2000; Masten, 2001). Direct-effects models hypothesize direct effects in multivariate correlational analyses. Two direct-effects examples are (a) when the relationship of high and low scores to outcomes is directly related to high and low scores on measures of adversity or (b) when a path diagram directly links specific variables with an outcome. Figure 17.1A, B illustrates the direct effects model. Indirect-effect models are those that hypothesize that the effect of variables, such as adversity or personal characteristics, is mediated by another variable, such as parental styles, as seen in Figure 17.1C. Interaction models hypothesize that the effects of adversity can be modified by individual characteristics or the environment. In general, variable-focused research indicates that adversity does not result in lasting or major effects unless moderating and mediating systems, such as parent or social protective factors, are compromised (Masten, 2001).

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Figure 17.1 Variable-focused research models: (A) main, (B) direct, and (C) indirect effects.

Person-focused research attempts to identify and describe the patterns of variables that naturally occur. This process often involves identifying persons with either positive or poor functioning and then examining what might contribute to these outcomes, or using cutoff scores on selected variables to categorize adversity subgroups and then examining outcomes in these groups. These types of person-focused designs often lack comparison low-risk groups, which are important to answering the question: do resilient children differ from children who are doing well but do not have high-risk characteristics? Masten (2001) also argues for more complex person-oriented models that include both health and maladaptive pathways of development in lives studied over time, giving special attention to turning points. These pathway models have a greater potential for providing intervention frameworks.

Approaches to Resilience Knowledge Development in Nursing Literature Resilience research in the nursing literature reflects a variety of approaches. The articles in Table 17.1 used concept analysis, integrative literature reviews, model development and testing, and methodological (measurement) synthesis to further knowledge of resilience. Some of the reviewed articles also proposed models of resilience in specific health contexts. For example, Bekhet et al. (2012) reviewed literature to consider

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resilience in family members of individuals with autism spectrum disorder, and Garcia-Dia et al. (2013) used concept analysis to consider resilience in individuals with HIV/AIDS. Haase and colleagues used a sequential mixed-methods approach to develop and test the Adolescent Resilience Model (ARM), renamed the Resilience in Illness Model (RIM) (Haase, 1987, 2004; Haase, Britt, Coward, Leidy, & Penn, 1992; Haase et al., 1999; Haase, Robb et al., 2014).

The data-based nursing studies fall into two categories of design. First are studies describing characteristics of a sample of participants who were designated, a priori, as having resilience. Such studies, for example, have looked at resilience in women older than 85 experiencing illness or loss (Felten, 2000; Felten & Hall, 2001), resilience in homeless adolescents (Hunter, 2001; Hunter & Chandler, 1999), and resilience in adult daughters of battered women (Humphreys, 2001). Second are studies of resilience conducted with a specific population but without a priori designation of participants as being resilient. Examples include resilience studies of adolescents with cancer (Haase et al., 1999) and resilience in children with asthma (Vinson, 2002). Although these studies fit into Masten's description of variable- and person-focused research, they do not reflect the complexity of design Masten recommended, to include both healthy and maladaptive pathways of development in lives studied over time, giving special attention to turning points (Masten, 2001). By their creative approaches to clarifying the patterns/processes/components of resilience, it is clear that studies conducted by nurses are increasingly interested in and adding to the knowledge base on resilience. More complex designs and interventions to address resilience seem to be logical next steps.

Specific Models of Resilience The articles in Table 17.1 that describe literature synthesis and concept analysis of resilience indicate the value that nurse scientists place on carefully developing theory. Models or theories of resilience have been increasing. Szanton and colleagues linked society to cellular levels of coping in older adults (Szanton & Gill, 2010; Szanton, Gill, & Thorpe, 2010). Individual-level resilience models include the following:

Mastery of chronic illness with resilience as an emergent outcome (White, 1995)

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A “CARE” framework (containment, awareness, resilience, and engagement) for guiding mental health practice (McAllister & Walsh, 2003) The RIM developed in the context of adolescents/young adults with cancer and other chronic conditions (Haase, 1999; Haase et al., 2014) The Inner Core Child Resilience Model for children with asthma (Vinson, 2002) A model of resilience in community-dwelling women older than 85 overcoming adversity from illness or loss (Felten, 2000; Felten & Hall, 2001)

In addition, a model of resilience in adolescents was proposed by Rew and Horner (2003), adapted by Ahern (2006), and used to guide clinicians who work with high-risk teens (Halloran, 2011). Some models propose a continuum of risk and protective factors. Other models were constructed with consideration of the perspectives of those experiencing the adversity. Potential interventions are proposed on the basis of three models (Ahern, 2006; Haase, 2004; Rew & Horner, 2003). These models differ in the specificity of targeted factors and in potential timing of interventions. Although there is less nursing literature on family or community resilience models, these models are being developed and used in practice with increasing frequency. The Family Resilience Model developed by McCubbin and McCubbin (1996) is supported in the literature on family resilience (Board & Ryan-Wenger, 2000; Svavarsdottir, McCubbin, & Kane, 2000; White, Bichter, Koeckeritz, Lee, & Munch, 2002). This model has been suggested as a framework for caring for those with chronic pain (West, Usher, & Foster, 2011). Other family models are also being proposed. Drummond et al. (2002) proposed and tested a model of family adaptation that identified family protective factors of appraisal, support, and coping as mediators of adaptation. Appraisal was a key variable predicting adaptation. Community-based models have been considered for drug education of adolescents (Brown, Jean-Marie, & Beck, 2010) and mental health promotion and mental illness prevention (Power, 2010).

Across the models of resilience, many adversity and positive concepts were inconsistently identified as antecedents, critical components, and outcomes of resilience. Antecedents usually included adversity (e.g., death, loss, illness, stressor[s], and homelessness). Protective factors were modeled as antecedents in only a few studies (Haase et al., 1999; Hunter & Chandler, 1999). Across several studies, especially those that viewed resilience as a trait, it was difficult to discern the role (e.g., mediator,

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moderator) of resilience-related concepts such as coping, hope, or mastery. These concepts were alternatively viewed as antecedent and critical component protective factors or as outcomes of resilience. For example, in some articles, coping is viewed as a mediating protective factor, whereas in others it is an outcome of resilience. Reflective of the general literature, many protective factors do fall into broad categories of factors classified as individual, social, or family.

It is clear that more work needs to be done to clarify the relationship among concepts that are correlated with resilience and those that influence resilience outcomes. To increase explanatory power, this work will most productively be done in longitudinal studies, with models that attempt to capture the full, integrative perspective of resilience.

Application of a Theory: The Resilience in Illness Model

Research to Develop the Model The RIM provides one example of how a theoretical model that is built on experiences of the population of interest can be useful to guide interventions. The context for the RIM was chronic illness in adolescents. Most of the research was derived from the perspective of adolescents with cancer; however, some studies included parent and health care provider perspectives.

To develop the RIM, two series of studies were conducted: (a) model generation studies, using inductive approaches and (b) model evaluation studies, involving instrumentation and exploratory model testing (Haase et al., 1999, 2014). The qualitative, model-generating studies provided a basis for the development of the RIM through the identification and clarification of salient concepts to be included in the model and through the use of the model as a qualitative means of evaluating subsequent model testing results. These studies were also guided by the Haase Decision- Making Process for Model and Instrument Development (Haase et al., 1999).

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Both protective and risk factors are included in the RIM. Three classes of RIM protective factors are hypothesized to positively affect resilience outcomes:

Class I, Individual Protective Factors, includes courageous or positive coping and derived meaning. Class II, Family Protective Factors, includes family adaptability, cohesion, communication, and perceived strengths. Class III, Social Protective Factors, includes connectedness with health care providers and social integration.

Two classes of RIM risk factors are hypothesized to negatively affect resilience:

Class IV: Individual Risk Factor is sustained defensive coping. Class V: Illness-Related Factors include illness perspective and illness distress.

The outcome factors of resilience include self-esteem, mastery/confidence, and self-transcendence, as well as quality of life, defined as a sense of well-being. Figure 17.2 shows the relationship between the protective and risk factors of the RIM, and these factors are related to specific variables as found in Table 17.2.

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Figure 17.2 The Resilience in Illness model.

Table 17.2 Adolescent Resilience Model Latent and Manifest Variables

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Research to Evaluate Instruments and Model Evaluation The quantitative model and instrument evaluation studies for the RIM were primarily done using latent variable structural-equation modeling approaches. The studies were done to evaluate the psychometric properties of the instruments used to measure each latent variable and to develop an appropriate measurement model. Based on the exploratory studies of the theoretical model, factors were identified that affect the development of resilience. The resulting RIM is being studied longitudinally and with the goal of guiding interventions.

Research Using a Model to Guide the Intervention Once the RIM was validated, it effectively guided evaluation in a multisite randomized controlled trial (RCT) of a therapeutic music video intervention for adolescents/young adults undergoing a stem cell transplant (Robb et al., 2014). These findings are described in Using Middle Range Theory in Research 17.1. In 2011, the RIM was adopted by the Children's Oncology Group—Nursing Discipline Committee as the organizing framework to guide all the clinical trials sponsored by the committee (Kelly et al., 2014).

USING MIDDLE RANGE THEORY IN RESEARCH 17.1

Source: Robb, S. L., Burns, D. S., Stegenga, K. A., Haut, P. R., Monahan, P. O., Meza, J., …, Haase, J. E. (2015). Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescent/young adults undergoing hematopoietic stem cell transplant: A report from the Children's Oncology Group. Cancer, 120, 909–917. doi: 10.1002/cncr.28355

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Research Purpose Adolescents/young adults often experience high distress during

hematopoietic stem cell transplant (HSCT). The purpose of this study was to test the hypotheses that therapeutic music videos would “(a) increase protective factors of spiritual perspective, social integration, family environment …, courageous coping, and hope-derived meaning …; (b) decrease risk factors of illness related distress … and defensive coping; and (c) increase outcomes of self-transcendence and resilience” (p. 910).

Research Design The study was an RCT.

Sample/Participants Participants were recruited from eight Children's Oncology Group

institutions. To be eligible, the participants needed to be aged 11 to 24 years, undergoing myeloablative HSCT for cancer, and able to read and speak English. The target number of participants was 130 adolescent/young adults but was not achieved.

Data Collection Participants were randomly assigned to the music video or low-dose

(audiobook), control group using 24 strata (eight different sites and three age groups: 11 to 14, 15 to 18, and 19 to 24 years). Both groups received six sessions (two per week) during the acute HSCT phase. For the treatment group, sessions 1 to 3 included singing, brainstorming, lyric writing, discussion, and song recording. Sessions 4 and 5 involved selecting the visual content for the video based on the previously developed song lyrics. In session 6, the treatment group participants viewed their videos. The control group selected an audiobook from a list of 15 that were determined to be age appropriate. They listened to and discussed the books during sessions. Evaluations were completed after the sixth session and 100 days posttransplant. Sixteen different instruments were used to measure the variables: illness-related distress, social integration, spiritual perspective, family environment, coping, hope-derived meaning, and resilience. To determine statistically significant differences between the two groups, a two-sided t test was used.

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Findings The treatment group experienced improved courageous coping

immediately after the sixth session and improved social integration and family environment 100 days after transplant. It was concluded that improved coping during treatment would likely result in better long- term adjustment.

Other Practice Applications of the Theory Much of the literature on resilience focuses on research, examining the correlations between resilience and health outcomes in a variety of populations. The articles that do address how resilience can be promoted are more frequently found in educational and public health peer-reviewed journals than in nursing journals. There seems to be an increased interest in the development of resilience in nurses. See Using Middle Range Theory in Practice 17.2 for a description of a resilience training program for ICU nurses.

USING MIDDLE RANGE THEORY IN PRACTICE 17.2

Source: Mealer, M., Conrad, D., Evans, J., Jooste, K., Solyntjes, J., Rothbaum, B., & Moss, M. (2014). Feasibility and acceptability of a resilience training program for intensive care unit nurses. American Journal of Critical Care, 23(6), e97–e105. doi: 10.4037/ajcc201447

Problem ICU nurses work in a stressful environment and often experience

psychological issues such as anxiety, depression, burnout syndrome, and posttraumatic stress. This distress may help explain the high turnover rate of ICU nurses, which has been reported to be 25% to 60% annually.

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Intervention Thirteen ICU nurses were randomly assigned to an intervention

group with 14 ICU from the same clinical academic institution randomly assigned to the control group. The 12-week intervention included the following:

1. Two-day educational workshop. This provided an introduction to resilience training and the types of psychological distress experienced by ICU nurses. The participants were provided with instruction on self-care and cognitive behavioral therapy. An expert conducted a 2-hour guided mindfulness exercise session and provided a compact disc that could be used during the intervention period. A 4-hour session on written exposure was also included.

2. Written Exposure Therapy. E-mailed prompts were provided to which participants were asked to write twelve 30-minute sessions. Topics that were suggested included challenges at work, feeling conflicted, and ruminating about sensitive issues.

3. Mindfulness practices. Each participant was to use the mindfulness activities for 15 minutes three times per week. Body scan and sitting meditation were the techniques to be used by the nurses.

4. Exercise. Membership to the wellness center was provided, and participants were asked to engage in aerobic exercise for 30 to 45 minutes at least three times per week.

5. Event-triggered counseling sessions. Events that triggered the sessions were a patient's death, participating in end-of-life discussion with family members, performing cardiopulmonary resuscitation, performing futile care for a terminally ill patient, caring for a patient with massive bleeding or traumatic injuries. Each session was 30 to 60 minutes and focused on cognitive behavioral approaches to challenge negative thoughts and promote resilience.

Members of the control group were not involved in any of the interventions but were asked to provide a record of their exercise.

Outcome All the nurses in the intervention group attended the workshop and

completed all the weekly writing sessions. The participation rates were slightly less for mindfulness exercises (66%) and physical exercise (88%). The average number of even-triggered counseling sessions was

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two. The participants rated their level of satisfaction with the activities high. Four main themes emerged from the written exposure exercises: (a) patient-centricity, (b) cognitive processing, (c) work structure, and (d) workplace relationships. Nurses in the intervention group had statistically significant lower levels of depression when compared to the control group. Both the intervention and control groups experienced a statistically significant reduction in PTSD symptoms and improved resilience scores. Resilience training was considered both feasible and acceptable to ICU nurses.

Several articles encourage health care workers to reinforce the resilience strategies of others. Ward et al. (2011) explored the additive and subtractive processes used by nonsmokers to never smoke and by smokers to quit smoking. Herrick et al. (2011) described strength-based approaches to prevent HIV in gay men. Other articles simply provide a description of recommended behaviors to promote resilience, for instance, in high-risk teens (Halloran, 2011) and social workers involved in the community (Megele, 2011). In addition to Megele's article identifying strategies to promote resilience in social workers, Aiello et al. (2011) discussed an intervention to build resilience in health care workers who would be required to deal with a viral pandemic, and Delport, Strydom, Theron, and Geyer (2011) described a support program for educators working with HIV/AIDs. This program, referred to as Resilient Educators (REd), included nine modules that consider health promotion, psychosocial impact of the pandemic, stigma, health care, and resilience, while providing background information and interactive activities.

There are also examples of substantial projects developed to apply a resilience framework for promoting healthy behavior. One such project is an “international and prospective application of resilience in school-based drug education, Project REBOUND [resilience-bound]” (Brown et al., 2010, p. 331). The approach was based on an analysis of literature that found (a) risk-based education was basically ineffective; (b) protective factors and risk factors are independent phenomena; and (c) resilience is a normative process that can be predicted in relation to caring connected relationships, opportunities for participation and contribution, and high expectations of self (p. 337). The education program developed to influence drug use behavior of young people was based on these three predictors. This drug education model included a Resilience Education (focused more on protective factors) with Risk Competence informational

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orientation (focused more specifically on the topic of drug use). Both were used in processional development for educators, counselors, and administrators, which involved six 1.5-day workshops. The workshops were designed to not only introduce them to the curriculum but also assist them to integrate the lessons to be taught into their own lives.

The curriculum was delivered in 90-minute lessons over a 16-week period. One of the first issues introduced was the necessity for authentic presence and openness to learn. Most of the Resilience Education was devoted to protective factors, addressing the importance of connection, participation and contribution, and high expectations for self. Finally, these topics were linked to decisions related to drug behavior. Following the focus on Resilience Education, the remaining sessions were devoted to Risk Competence. In those sessions, individual risk is explored, drug information is provided, critical thinking is facilitated, and self-awareness with special emphasis on strengths is encouraged. Project REBOUND has been supported by the Mentor Foundation and the European Union. It was developed to be first implemented in Germany and then be adopted throughout Europe and the United States. As it is implemented, evaluation will occur at each step of the program.

Several other examples of implementation strategies to promote resilience are found in Table 17.3. These studies demonstrate the usefulness of the theory for patient populations and health care professionals.

Table 17.3 Examples of Theory in Practice

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Instruments Used in Empirical Testing of Resilience Measurement is an approach to knowledge development for resilience that is gaining more attention (Ahern, Kiehl, Sole, & Byers, 2006). Windle, Bennett, and Noyes (2011) screened close to 3,000 peer-reviewed articles, published from 1989 to September 2009 to identify published resilience scales. They conducted a systematic methodological review of these scales, applying established quality assessment criteria to evaluate their psychometric properties. Windle et al. identified 15 scales, some with refinements and all self-report instruments; the earliest was published in 1989 and the most recent in 2008. These scales provided measurements for all population age groups, children through older adults. Three scales, all developed for use with adults, were determined to have the best psychometric properties: (a) the Connor-Davidson Resilience Scale, (b) the Resilience Scale for Adults, and (c) the Brief Resilience Scale. At best, the quality of these questionnaires would be considered moderate. All 15 scales are described by target population, mode of completion, number of items, purpose, and quality assessment. In addition, complete references and comments on theoretical background are provided. It was noted that

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different approaches to measuring resilience has resulted in lack of clarity related to potential risk factors and protective processes, and a number of the scales are in early stages of development and require further validation.

The resilience scale with the widest application is the Resilience Scale (Wagnild & Young, 1993). This scale designed with a two-factor structure, involving personal competence and acceptance of self and life, has been used in studies that represent different cultural and age samples.

Most quantitative studies of resilience used existing instruments or developed instruments to measure numerous variables in proposed models. However, in many cases, it is not clear whether the instruments were derived from theories that are congruent with the conceptual frameworks or the philosophical approaches that were being used in the studies. Haase et al. (1999) describe one approach to identifying and/or developing instruments that is clearly linked to the emerging RIM theory. Mixed methods were done in a series of studies to develop and test the RIM and to identify or develop the instruments used to evaluate the model (Haase, 1987; Haase & Rostad, 1994; Haase et al., 1992, 1999). Decision trees were used to decide on labels and definitions for each model factor and to decide whether to use existing instruments or ones developed to measure the model factors. This iterative process of decision making sought to retain the inductively derived meanings from the qualitative studies while taking advantage of existing theory and instruments. The result was a set of 15 instruments to measure manifest variables—eight existing instruments meeting established criteria for reliability and validity and seven new instruments. To test the RIM and instruments, latent variable instrument and model-testing studies were done (Haase et al., 1999, 2014).

It is clear that additional measurement work is needed to further the science of resilience from a nursing perspective. Cultural considerations in measurement are not well addressed. Measurement in nursing research on resilience needs to consider the issues of boundaries, including trait/process and physiological/psychological. Measurement also needs to focus on differences in resilience based on developmental factors, including age.

Summary The work nurse scientists have accomplished to add to the body of

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knowledge on resilience is considerable, but much work still needs to be done. Areas of strength within the nursing literature continue to include the following:

Careful attention to theory, both by clarifying concepts through literature analysis and synthesis and by using qualitative methods that explore experiences of resilience from the perspectives of those who have experienced adversity. The recognition of resilience as a positive health concept and the recognition of resilience as a dynamic process.

To advance the science, much work remains for nurses in collaboration with scientists from other disciplines. Some specific recommendations can be made:

Continue efforts on measurement issues, to ensure that instruments are context and culturally sensitive, meaning based, and time sensitive. Conduct longitudinal, prospective studies of resilience to test integrative models. Develop and test interventions planned to manipulate targeted variables that are promising to influence resilience outcomes. Take advantage of the rapid advancements in neurocognitive sciences to include biological markers that may contribute to the existing knowledge of resilience.

Critical Thinking Exercises

1. The RIM has primarily been developed for use in adolescents/young adults with cancer. Identify other populations where this model could be used to guide further research. What issues would you need to consider before applying the model to another population?

2. Develop a potential intervention targeted at one or more of the protective factors in the RIM that may influence resilience and quality of life in adolescents and young adults (AYAs).

3. Describe how the middle range theory proposed in this chapter helps refine your previous conceptualization of resilience.

4. Describe the benefits of meaning-based models or strengths-based research in your area of interest.

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Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of Resilience.

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18 Planned Change Brian Goodroad, Marjorie Webb, and Timothy S. Bredow

Definition of Key Terms

Planned change Change may occur randomly or as part of natural evolution. However, planned change as reviewed here implies a deliberative process. Such a process is controlled and suggests a conscious process undertaken to alter the status quo.

Change agent As in chemistry where a catalyst helps a reaction to proceed, a change agent is a person or event that aids or promotes a change to take place in a person or an organization.

Change process The change process is the series of events that occur over a period of time to bring a person or an organization to a different place or level of operation that they have not been at, as evidenced by either a shift in behavior or a new and different processes for carrying out business operations. This process is impacted by both internal and external people and/or events.

Introduction Grove, Burns, and Gray (2013) offered that as a practice discipline, nursing's ultimate goal is to provide the best evidence-based care to

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enhance the health of the patients and families we serve. Nurses in public health practice and in advanced nursing practice roles are further challenged to work toward population health enhancement. This challenge is especially true in the development and aims of the highest level of practice preparation in nursing: the Doctor of Nursing Practice (DNP) degree–prepared nurse in direct or indirect care roles (American Association of Colleges of Nursing, 2006), the master's-prepared clinical nurse leader (American Association of Colleges of Nursing, 2013), and the master's-prepared nurse administrator (American Association of Colleges of Nursing, 2011). These advanced nursing practice role competencies underscore expected expertise in change agent leader, process improvement implementation, and practice outcome evaluation proficiency. The nurse at any level of practice should utilize theories to guide planned behavioral change to improve individual and population health, as well as theories to direct planned practice improvement on the unit/clinic, organization, or community level.

Although nursing practice, and the DNP specifically, have previously been accused of being too atheoretical, Dahnke and Dreher (2011) suggested that perhaps it was the type of theory used that was not so applicable in nursing practice. Dahnke and Dreher suggested that middle range theories, meant to guide practice change, are those most applicable for advanced nursing practice. The middle range theory or conceptual framework is often meant for application in specific practice situations. Smith and Parker (2015) noted that middle range theories hold great promise for increasing use of theory in nursing practice and for the development of testable practice strategies. The application and use of a middle range theory tends to be relative to a specific practice setting or environment. A model or theory appropriate with one health behavior, change process, or population may prove spurious when empirically tested with other behaviors, groups, or organizations. Practice knowledge gained through application and use of a middle range theory may result in the modification or discarding of a theory or concepts. Finally, a middle range theory guides the application and generalization of research findings back to practice reality and practice knowledge development. Thus, the relationship between theory, research, and practice is reciprocal in nature and is mutually beneficial.

In an attempt to improve individual and population health, nurses often utilize theories to guide interventions aimed at individual and community behavioral changes. Glanz, Rimer, and Viswanath (2008) suggested that

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change theories or conceptual models can help investigators during all stages of planning and implementing research or evidence-based change projects. Theories guide investigation as to why people behave as they do, help to determine what one needs to know before developing and organizing an intervention program, and provide insight on how to build the intervention to best reach and affect its intended audience. Theories also identify what should be monitored, measured, compared, or evaluated in intervention research. Evidence supports positive outcomes of theoretically based change interventions (Glanz et al., 2008). To design and test an intervention aimed at affecting an individual's health behavior without theoretical guidance seems inappropriate given the available knowledge. Additionally, the use of an implementation theory based on evidence to guide the development of the best process for ensuring diffusion of an intervention or planned change across a health system, organization, or unit seems like the best evidence-based practice available. One might wonder why using a process implementation theory might be needed. After all, don't we have the patient's best interest at heart in our change, and isn't that the most important thing? Implementation theories provide the overall guidelines for all aspects of planned practice change including assessment, implementation, and evaluation. For too long, nurses have identified issues in practice and tried to implement changes to affect health outcomes based on best intentions and a desire to provide “good care.” However, without a systematic approach based on implantation theory, the change planner may not have included all stakeholders, nor worked to engage buy-in, nor fully assessed the individual's and organization's readiness for change. This attempt at practice change would certainly be more likely to fail.

This chapter reviews three common theories aimed at affecting individual health behavior: (a) the health belief model (HBM), (b) the theory of reasoned action (TRA), and (c) the transtheoretical model and stages of change theory. Two additional theories aimed at system or community implementation of change include Lewin's theory of change and Rogers' diffusion of innovations theory.

Historical Background The practice discipline of nursing has a long history of examining how we might affect change on an individual level related to improving health

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choices and the use of planned change theories to change practice on an organizational level. Lewin (1947) was one of the first to take the concept of change and propose a model to try to explain the relationship of the concepts. Throughout his career, Lewin was interested in resolving social conflict, which he felt was the only way to improve the human condition (Burnes, 2004). His change theory was influenced by his earlier work in field theory, group dynamics, and action research. His work in group dynamics, with his emphasis on focusing on group change instead of individual change, was an integral component of his three-step model of planned change (Burnes & Cooke, 2013). Other attempts to identify additional factors that affect change built upon Lewin's groundbreaking work. The HBM was first presented in 1975 along with the TRA in that same year. The TRA preceded and gave rise to the theory of planned behavior (TPB) in 1991. All of these theories are considered as borrowed theories for nursing purposes because they are authored by nonnurses but can readily be used by nursing professional to help describe, explain, or predict change that happens in a variety of nursing situations in clinical practice. The Health Promotion Model published by Pender in 1982 is a nurse-authored middle range theory that is covered in Chapter 15 of this text. Finally, the transtheoretical model (TTM) for change was published in 1997. Since then, much work has been done to determine the strength of the relationships between the factors and concepts proposed by each of these theories. Three of these borrowed planned change theories will be presented in this chapter.

Definition of Theory Concepts Through the theories focused on individual behavioral change, several concepts are strikingly similar. Although the concepts may have slightly different names or perhaps more broad definitions, the process change for the individual or organization contains concepts across all theories. The concepts are planned change, change agent, and change process.

The Health Belief Model The HBM was developed by social psychologists (Becker & Maiman,

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1975) and the U.S. Public Health Service in an effort to explain why healthy people did not engage in programs to prevent or detect illness. During the ensuing years, the model has been modified to include behavior in response to diagnosed illness, especially with one's ability to adhere to medical regimens and to apply to people's beliefs regarding symptoms (Clark & Janevic, 2014). The model is premised on the belief that people will take action to prevent or screen for illness if they perceive themselves to be susceptible to the condition; believe that occurrence of the condition has serious consequences; believe that the course of action they may take will ameliorate or prevent the condition; and believe that the benefits of taking action outweigh the barriers to behavioral change (Champion & Skinner, 2008). These dimensions make up the structure of the HBM and define factors that influence the individual's likelihood of engaging in the recommended behavioral change.

Description of the Theory Perceived susceptibility represents the individual's subjective perception of his or her own risk of contracting a health condition. In individuals with an already diagnosed illness, this component encompasses one's acceptance of the diagnosis, beliefs of disease progression, and susceptibility to illness in general. Perceived severity addresses one's beliefs regarding the seriousness of contracting an illness or leaving it untreated. Both medical and clinical consequences affect this dimension and include such factors as death, disability, pain, and other symptoms. Additionally, social factors related to illness such as effects of contracting the illness on family, work, and social relationships are included here.

The combination of susceptibility and severity has been labeled as perceived threat. As depicted in the model, susceptibility to a perceived threat of disease, illness progression, or adverse symptom affects the individual's likelihood of making a healthy behavioral change, but is not the only intervening factor.

Likelihood of action is also affected by perceived benefits and perceived barriers to behavioral change. Perceived benefits of behavioral change may be health related (decreased symptoms, decreased morbidity and mortality) and nonhealth related (make a loved one happy and save money). A belief that the action taken will be efficacious in preventing or reducing disease effects is necessary, in addition to perceived

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susceptibility and severity behavioral change, for healthy behavioral action.

Potentially negative aspects of a particular health action are the perceived barriers. These barriers include such factors as expense, level of danger (i.e., negative side effects or iatrogenic outcomes), unpleasantness, inconvenience, and length of time for treatment. Although not presented in the early model, the concept of self-efficacy, or the belief in one's ability to take health action, is now postulated as part of the HBM. Rosenstock, Strecher, and Becker (1988) suggest that the lack of self-efficacy is perceived as a barrier to successful health behavioral change. Janz and Becker (1984) offer that a subconscious cost–benefit analysis of the benefits versus the barriers occurs. In the end, the perceived benefits minus the perceived barriers to behavioral change affect an individual's likelihood of action.

Application of the Theory in Practice Janz and Becker (1984) performed an extensive review of 29 studies testing all or part of the four major components of the HBM (Fig. 18.1) from 1974 to 1984. Preventive health behavior was examined in 24 of the studies and sick role behavior in 19, and three addressed clinic utilization. Prevention behavior included influenza immunization during the Swine flu outbreak of 1976 and screening behavior such as genetic testing, breast self-exam, high blood pressure screening, and consistency of preventive health behaviors such as seat belt use, exercise, smoking cessation programs, and regular health checkups. Sick role behaviors included adherence to medications and diet regimens in patients with hypertension, diabetes, and renal failure. Adherence to prescribed medication regimens for children by parents was also examined. The authors combined these findings with the 17 published studies prior to 1974 to offer a comprehensive analysis of the body of knowledge regarding testing of the HBM through 1984.

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Figure 18.1 Belief Model. (From Pender, N., Murdaugh, C., & Parson, M.A. (2015). Health promotion in nursing practice (7th ed.). Boston, MA: Pearson.)

Results from this review indicated that the component of perceived barriers was the most powerful single predictor of preventive and sick role health behavior among all components of the HBM across all studies. Perceived susceptibility was a stronger predictor of preventive health behavior than were perceived benefits, and the reverse was true for sick role behavior. Both of these components were important predictors overall. Perceived severity was the weakest predictor of health behaviors and was strongly related to only the sick role behaviors. These findings make theoretical sense as well. A person without disease or diagnosis may be more influenced to prevent an illness if perceived to be susceptible to the illness. For those with diagnosed problems, the belief of severe disease effects or symptoms would drive secondary preventive medication or diet behavior.

More recently, the HBM or concepts of the HBM has been utilized in nursing research with varying levels of success to understand cancer screening behavior adoption (Thomas et al., 2013), Pap smear and cervical cancer screening follow-up (Guvenc, Akyuz, & Acikel, 2011), and vaccine acceptance rates for individuals on dialysis (Adams, Hall, & Fulghum, 2014).

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Although the HBM has been widely studied and its predictive ability has been supported in a number of behaviors and illnesses, it is not without limitations. One criticism is that the majority of the research conducted on the model has inappropriately tested all variables as though they are equally weighted or have selected only certain dimensions (e.g., perceived barriers) for study. Thus, the model has not been tested as a model, rather as a set of independent variables. Additionally, the HBM model focuses on affecting an individual's health-related behaviors and may need to be adapted to influence community or population health (Clark & Janevic, 2014).

Theory of Planned Behavior Because the TPB is an extension of the TRA, and current research often presents the combined theories within one conceptual framework, the TBC in relation to its extension of the TRA is explored in this section. The TRA was introduced in 1975 by Martin Fishbein and examines the relationships between beliefs, attitudes, intentions, and behavior. During this time, studies were indicating little or no correlation between attitudes and behavior, and some theorists proposed eliminating attitude as a factor underlying behavioral action. Fishbein proposed that one's attitude toward a behavior is a much better predictor of undertaking that behavior than is attitude toward the target at which the behavior is directed (Montano & Kasprzyk, 2008). For example, in a person on medications for hypertension, the individual's attitude toward taking the medication is more predictive of adherence than is the attitude toward HTN as a disease itself. The TRA was revised by Ajen to include the addition of the variable of perceived control over behaviors and was renamed the TPB.

Description of the Theory The TPB asserts that the most important predictor of behavior is an individual's behavioral intention (Montano & Kasprzyk, 2008) (Fig. 18.2). Behavioral intention is the perceived likelihood of performing the behavior and is posited by Ajzen (1991) to be the best predictor of likelihood of undertaking the behavior. Intention is affected by three types of beliefs including behavioral beliefs, normative beliefs, and control beliefs.

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Intention is directly determined through one's attitude toward performing the behavior and subjective norm. Each dimension consists of two determining factors. Attitude toward the behavior is determined through behavioral beliefs (beliefs about the outcomes or attributes of performing the behavior) weighted by evaluations of those outcomes or attributes. Therefore, an individual with strong beliefs that mostly positive outcomes will result from performing a behavior will have a positive attitude toward that behavior. A person with mostly negative beliefs of the outcome of a behavior will have a negative attitude toward that behavior.

Figure 18.2 Theory of Reasoned Action and Theory of Planned Behavior. (From Montano, D. E., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 67–96). San Francisco, CA: Jossey-Bass.)

Subjective norms are determined through an individual's perceptions of whether or not other individuals important to them approve or disapprove of the behavior (normative beliefs) weighted by the individual's motivation to comply with those referent others. Thus, a person who believes that others think a behavior should be performed, and who is motivated to comply with those expectations, will have a positive subjective norm. A negative subjective norm is a result of an individual's belief that important

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referents believe he or she should not undertake the behavior. Elder, Ayala, and Harris (1999) postulated that the dimension of

perceived behavioral control is similar to the concept of self-efficacy. Montano and Kasprzyk (2008) further stated that perceived control includes the two components of control beliefs (the presence or absence of resources for and impediments to behavior performance) weighted by perceived power (the impact of each resource and impediment to facilitate or prevent the behavior).

Application of the Theory in Practice The HIV prevention behavior of condom use has been studied using both the TRA and TPB. Jemmott and Jemmott (1992) surveyed sexually active unmarried African American women undergraduates at an inner-city university. Multiple regression analysis revealed that participants with favorable attitudes toward condoms and who perceived subjective norms supportive of condom use reported greater intention to use condoms. Women's positive condom use attitudes were greater predictors of intent to use condoms than were positive subjective norms. Conversely, Ross and McLaws (1992) found that in 173 men who have sex with men, subjective norms were more predictive of condom use intent than were attitudes toward condoms. An environment of safer sex expectation that developed in the gay community during the AIDS epidemic may explain this fact. The perception of an entire community's support of condom use was most likely widespread in the time Ross and McLaws conducted their study.

More recent nursing studies have utilized the TPB to predict nurses' blood pressure monitoring behavior (Nelson, Cook, & Ingram, 2013), predict nurses' intention to integrate research evidence into clinical decision-making practice (Côté, Gagnon, Houme, Abdeljelil, & Gagnon, 2012), and overweight adolescents' beliefs regarding overweight (Rhoades, Al-Oballi, & Penprase, 2011). See Table 18.1 for additional information about how this theory has been applied to practice.

Table 18.1 Examples of Research for Application to Practice

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Transtheoretical Model The TTM (Prochaska, Redding, & Evers, 2008) is so named because it incorporates elements from a number of other psychotherapy and

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behavioral change theories into its structure. This model was developed by Prochaska and DiClemente in the late 1970s and evolved through studies examining the experiences of smokers who quit on their own with those requiring further treatment to understand why some people were capable of quitting unaided. It was determined that people quit smoking if they were ready to do so. Thus, the TTM focuses on the decision making of the individual and is a model of intentional change (Clark & Janevic, 2014). The TTM operates on the assumption that people do not change behaviors quickly and decisively. Rather, change in behavior occurs continuously through a cyclical process. The major premise of the model is that people progress through a series of stages when they attempt to change behavior. Six stages have been proposed and are depicted below.

Description of the Theory The first stage, precontemplation, includes people who have no intention of taking action in the foreseeable future. Prochaska and Norcross (2001) defined foreseeable future as within the next 6 months. Revisions of this stage lead to three subclassifications noted as (a) unaware (individual has no idea that there is problem behavior), (b) uninvolved (individual knows that the behavior needs to be changed but does not perceive the problem as urgent), and (c) undecided (considering the positive and negative consequences of the change) (Elder et al., 1999). Contemplation is the stage in which people intend to change within the next 6 months. Individuals are becoming aware of the pros of changing, but remain acutely aware of the cons of change. The next stage, preparation, includes people who intend to take action in the immediate future (usually within the next month). Often, some significant action has been taken in the last year, and these people have a well-defined plan for undertaking the behavioral change. Action is the stage in which people have made specific modifications in their lifestyles within the past 6 months. Usually, subjects in this stage are required to meet and sustain some observable behavior (i.e., abstinence from smoking) for at least 6 months. After the time has elapsed, the behavior has become ingrained into the individual's life and they may enter the maintenance stage. Individuals in this stage work to prevent relapse, but don't usually need to use as many processes of change to maintain the stage. The termination phase is the sixth stage that is appropriate only for some behavior. In this stage, individuals have no temptation for relapse and experience 100% self-efficacy to maintain the

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behavior (Prochaska et al., 1997). Relapse is an expected part of the cyclical change process and occurs

when the client reverts to a previous behavior. It is a normal part of the change process, and the role of the health care provider is to help the individual renew the change process without becoming demoralized. This usually means starting the change process again at an earlier stage of change (Finnell & Osborne, 2006). Ten processes of change have been identified. These processes are strategies and techniques used to help modify behaviors. Strategies may be well-thought out, subtle, or ingrained responses or may come from external pressures. Each stage of change is associated with processes of change appropriate for movement through the stage. Decisional balance and self-efficacy are the remaining two central concepts of this model. Decisional balance reflects the individual's weighing of the pros and cons of changing. Research using this model has revealed that as people move through the stages, the pros of changing must increase twice as much as the cons must decrease (Prochaska & Velicer, 1997).

Application of the Theory in Practice The TTM has been applied in multiple clinical settings including primary care and acute care (Fig. 18.3). Additionally, the model has been utilized to examine community-based health behavior. Early development of a measure for stage identification for adherence issues is promising. Willey et al. (2000) examined a measure aimed at identifying the stages of change as related to HIV and hypertension medication taking behavior (n = 161 HIV and n = 731 hypertension patients). Construct validity in the HIV group was demonstrated by association between stage of change measure and adherence by MEMS cap (p < 0.001). Additionally, predictive validity was noted by significant association between stage of change medication adherence and electronically measured adherence for 30 days (p < 0.03). Although promising for use in the future, the application of this measure and the meaning between stage and the appropriate medication intervention/s have yet to be determined. Furthermore, while studies have examined the stages and the processes of change, the effect of stage-based medication interventions on behavior has yet to be determined.

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Figure 18.3 The Transtheoretical Model. (From Prochaska, J. O., Redding, C. A., & Evers, K. E. (2008). The transtheoretical model and stages of change. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 97–121). San Francisco, CA: Jossey-Bass.)

More recently, the TTM has been used to examine adoption of such health behaviors as cancer screening, HIV and STD risk reduction behaviors, and physical activity. Furthermore, a number of meta-analyses have shown support for the strong and weak principles of change. The principles note that for an individual to move from precontemplation to action, one needs to experience approximately 1 standard deviation (SD) increase in his or her perceived “pros” of changing and about one-half SD decrease in the “cons” (Clark & Janevic, 2014). The clinician can use this information to gauge the type of health promotion message he or she is using with the client/patient.

A criticism of the TTM as a whole is that a good deal of the research completed on the model has included only partial use. Most frequently, studies have utilized the stage-based assessment to determine readiness to change and have tailored interventions to then work with the client/patient in the identified stage. Therefore, the model as a whole, with the recommended process of change, is not often used, and little application knowledge can be drawn from the limited known about the interventions aimed to enhance the process of change.

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Organizational Change Theories

Lewin's Theory of Change Kurt Lewin wrote “Change and constancy are relative concepts: group life is never without change, merely differences in the amount and type of change exist” (Lewin, 1947, p. 13). The “differences in the amount and type of change” are ever present in the field of health care. One example of a large change in health care in general and nursing in specific is the implementation of Universal Precautions in the mid-1980s. Many nurses practicing now would be surprised at how difficult it was for nurses to change practice by wearing gloves for every interaction in which exposure may be likely and not just for interactions where they felt that contamination would be likely. Somehow, this change was implemented and adopted and became the new status quo. How were health care systems able to implement this change? How did individual nurses and health care workers decide to adopt this change for themselves?

Kurt Lewin described constancy as “a quasi-stationary equilibrium” (Lewin, 1947, p. 13). “Quasi-stationary” is a brilliant description of the professional lives of nurses. There is no health care system in the United States that is not constantly in a state of equilibrium with driving and restraining forces. The prominence of change in the field of nursing is so great that nurses have established a new doctoral degree, the DNP, in part to implement change. The main goal of the role of the DNP is translation of research or changing practice to reflect the current level of evidence.

Description of the Theory Lewin's theory appears deceptively simple with only three components to planned change: unfreezing, moving, and refreezing (Lewin, 1947). The difficult part of this theory involves identifying and understanding driving forces and restraining forces of the planned change (Fig. 18.4). The first step of the theory, unfreezing, involves destabilizing the “quasi-stationary equilibrium” (Burnes, 2004). The individual, group, and/or institution must come to recognize that the current pattern of behavior is no longer the best way of doing things. This is where the driving forces and restraining forces

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are in play. Driving forces are the events or circumstances that make the change at best appealing and at worst at least necessary. Restraining forces are the events or circumstances that inhibit change. In order for the change process to begin, the driving forces must be larger than the restraining forces. Although driving forces and restraining forces are easily defined, they are not always easily identified in an institutional setting. Many factors such as group norms, psychological safety, and individual and group beliefs are a part of the forces. The change agent must take time to reflect on as many restraining forces as possible, since they can be difficult to overcome.

Figure 18.4 Lewin's Theory of Change. (From Garon, M. (2014). Change and innovation. In D. L. Huber (Ed.), Leadership and nursing care management (5th ed., pp. 37–54). St. Louis, MO: Elsevier.)

Once unfreezing has occurred, the moving step can follow. Moving is where the actual change takes place. In essence, this step should be easier than unfreezing because once the process has come to this point, the driving forces were able to overcome the restraining forces. Moving, however, is not the end of the process. The next step is refreezing or ensuring that the changed way of operating is a part of the new “quasi- stationary equilibrium.” The new quasi-stationary equilibrium becomes the status quo and, technically speaking, the new environment for the next process of change.

Application of the Theory in Practice Using Middle Range Theory in Practice 18.1 provides an example of using Lewin's theory in which two change agents (the director of research and a DNP candidate) worked together to change the existing system of monitoring patients who had pacemakers implanted.

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USING MIDDLE RANGE THEORY IN PRACTICE 18.1

Source: Tops, L. F., Schalij, M. J., & Bax, J. J. (2009). The effects of right ventricular apical pacing on ventricular function and dyssynchrony. Journal of the American College of Cardiology, 54, 764–776. doi: 10.1016/j.jacc.2009.06.006

Problem New research shows an association between pacemaker dependence

and the development of systolic heart failure (HF) in a select group of patients (Tops, Schalij, & Bax, 2009). This condition is referred to as pacemaker-induced dyssynchrony. Researchers reported a 25% to 40% risk of developing HF in this patient population (Tops et al., 2009). A midsized cardiology clinic in the Midwest already had a system for monitoring patients with pacemakers in place and made the decision to implement a screening process to detect the development of HF in patients with pacemakers as early as possible.

Nursing Intervention Originally, patients with pacemakers were followed through the

clinic's device clinic and were evaluated by device interrogation to determine the percentage of time that the pacemaker is actually being used to pace the heart (many patients are not completely dependent on their pacemakers). The proposed change was to have patients whose pacemaker was pacing more than 50% of the time have an echocardiogram performed to evaluate for HF prior to their next visit with their cardiologist. Echocardiography is the gold standard for diagnosis of systolic HF (Yancey et al., 2014).

Lewin (1951) discusses three steps in the change process: unfreezing, change, and refreezing. Within the model, there is a driving force for change and a resisting force for change as well. The change at the cardiology clinic was to add an additional step in the device clinic work process during the 1-year postimplant follow-up visit. In the device clinic, the usual frozen process of scheduled device interrogations had to be unfrozen. In this situation, the decision to change the process was from the director of medical research. The

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change was initiated from the top down. In order to implement this change, driving forces and resisting

forces had to be identified. One potential resisting force was individual cardiologists who felt that only they should order diagnostic tests for their patients. Another potential resisting force was the device clinic staff. Determining the percentage of pacing was a normal step in the work process, but ordering an echocardiogram would be an additional step in the workflow. In order to facilitate change, the change agents crafted a letter to the cardiologists explaining the consequences of pacemaker-induced dyssynchrony and the necessity of screening for HF in this patient population. Approximately 1 month later, the director of medical research presented the planned change to the cardiology group as a whole and the group agreed to allow the implementation of echocardiograms for patients who were found to be paced more than 50% at their 1-year postimplant checkup.

Outcomes In this clinic, the device clinic staff already had a close working

relationship with the research staff. Some of the staff was actually involved in research projects about this topic. That was helpful to attain staff buy-in for the change. Additionally, the device clinic staff is familiar with change in their work environment and experience change in protocols somewhat frequently. In that regard, having changes in how protocols are done is somewhat of an office norm. In addition, the registered nurses (RNs) in the device clinic have long-standing relationships with pacemaker patients. They develop a caring relationship with this patient population and have a genuine interest in the patient's well-being. In light of that, adding a step in the work process was acceptable considering they may be instrumental in diagnosing HF early enough for optimal treatment.

Thus, the potential resisting forces actually became driving forces in this change project. The driving forces were greater than other resisting forces so that unfreezing was attained. The moving stage was fairly simple in that one additional step was added to the existing protocol. The clinic did also attain refreezing as the protocol to perform echocardiography on the appropriate patients with pacemakers is still in place. This area of the clinic was able to establish a new quasi-state of equilibrium.

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Rogers' Diffusion of Innovations Theory Everett Rogers' (2003) diffusion of innovations theory for new knowledge dissemination and adoption has in the past several years become more widely cited in the health care change literature. Rogers defines diffusion as a special type of communication concerned with new knowledge diffusion. This communication is a process in which participants create and share information with one another in order to reach a mutual understanding. Because the process involves new information, there is a degree of uncertainty on the part of the receivers or people or social systems in which adoption of the innovation is expected to occur. The innovator utilizes the innovation development process and the Innovation- Decision Process to implement new knowledge or behavior and utilizes information in hopes of ameliorating uncertainty among adopters. Central to the Rogers model is consideration of characteristics of the innovation itself and attributes of the adopters that can affect success of the innovation diffusion across the group. Rogers defines the process of diffusion that includes an innovation, communication, time, and social systems. Rogers connects these concepts to one another noting that “The main elements in the diffusion of new ideas are (a) an innovation (b) that is communicated through certain channels (c) over time (d) among the members of a social system” (p. 36).

Description of the Theory The innovation development process is the entire time and activities that occur between one person becoming aware of the need for change through adoption and diffusion. Rogers (2003) defined five steps in this process: (a) awareness, (b) interest, (c) evaluation, (d), trial, and (e) adoption. Awareness, as defined by Rogers, is when disequilibrium is introduced into the system, creating a need for change. This is analogous to Lewin's “unfreezing” category. Interest, evaluation, and trial are stages in which change planners gather all available information and solve any problems, develop a detailed plan of change, and test the innovation. Mitchell noted the consistency with those three stages in diffusion of innovations with the “moving” stage in Lewin's theory. Finally, adoption occurs and is maintained in the system. This is also similar to the “refreezing” stage in the Lewin theory.

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The innovation decision process is the procedure through which an individual, group, or institution passes while considering and then implementing a new idea or innovation. This five-stage process includes knowledge, persuasion, decision, implementation, and confirmation (Rogers, 2003).

Rogers (2003) described knowledge as the first stage in the sequential process of innovation decision making. Knowledge occurs when a person (or other decision-making party) becomes aware of the innovation and gains understanding of its function and potential use. DiCenso, Ciliska, and Guyatt (2005) noted that the innovation adoption process begins with identification of the most current and highest level literature available. Furthermore, DiCenso et al. suggested that there is a hierarchy of preprocessed sources that includes the following levels from highest to lowest: (a) systems level includes practice guidelines, clinical pathways, or evidence-based textbook summaries; (b) synopses of syntheses level include synopses of systematic reviews; (c) syntheses level is a systematic review of all the evidence addressing a clinical area; (d) synopses of single studies; and (e) single studies. When finding or developing knowledge for evidence-based innovation, one should search for the highest level and most current information available. It is only after identifying this literature that one may move to the next stage.

DiCenso et al. (2005) suggested that during the persuasion stage, decision makers and other practitioners form opinions about the innovation and consider its consequences. Characteristics of the innovation, organization, environment, and individuals involved need to be assessed for influence on the decision to adopt or reject an innovation.

Rogers (2003) noted that the characteristics specific to the innovation include its perceived relative advantage compared to current practice and compatibility with the existing values, beliefs, and needs of the organization. Also important is the trailability of the innovation defined as the extent to which the innovation can be adopted in segments or on a small scale in which adopter may “try out” the innovation to determine its advantages and disadvantages. It is also important that the innovation's benefits be observable to the adopters. The measurable outcomes should be indicators valued in the organization or unit. Finally, the complexity of the innovation is important as well. Innovations are more likely to be adopted if they have higher rates of perceived advantage, compatibility, trailability, and observability and have low levels of complexity.

Individual characteristics assessed include opinion leadership or the

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level of influence one unit of change has on others. Innovativeness or the degree to which an individual is relatively earlier in adopting new ideas than are other members of the social system, and likely rate of adoption is also important. Rogers (2003) defines adopter categories or classifications of the members of the social system based on their innovativeness. These categories include innovators, early adopters, early majority, late majority, and laggards. Haider and Kreps (2004) note the importance of findings innovators and working to make them champions for the innovation as well as the early inclusion of those laggards who have high levels of organizational influence.

Environmental characteristics important in assessment include decision-making autonomy, urban or rural nature, prestige, competition, and peer pressure. Environments that have more autonomy are urban, understand the prestige in providing innovative care, and engage in a sense of competition with other care systems are more likely to adopt innovations supported by current and high-level literature.

Important organizational characteristics include structural influences such as complexity and functional differentiation. Also, workplace culture, communication systems, leadership support, and resources for innovation are important in assessment. Rogers (2003) noted that organizations with greater complexity and functional divisions have higher rates of innovation adoption. Also, workplace culture that values use of research evidence has functional communication systems, decision making that is decentralized, and whose leaders value the change is more likely to successfully adopt new ideas.

Key stakeholders are those individuals or groups who can directly or indirectly affect the decision to adopt the innovation (DiCenso et al., 2005). It is important to have the early involvement and support of those identified as key stakeholders. A stakeholder analysis will help determine the values, beliefs, and interests of the key decision makers. Through this analysis, champions of the innovation are identified. Additionally, the decision is made to either adopt or refuse to adopt the innovation.

Rogers (2004) described implementation as the new idea or innovation being put to use in the social system. DiCenso et al. (2005) offered several strategies to promote implementation of an innovation. Those methods most likely to result in adoption of the innovation are multifaceted in nature. DiCenso suggests that education conducted by a peer with individuals in their own practice settings is the most effective with changing provider prescribing and ordering practice. Additionally,

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reminders provide reinforcement of the innovation. Technology should also be used as appropriate.

Rogers (2003) noted that in the confirmation stage, evidence of adoption is examined. Additionally, the adopter seeks reinforcement for the innovation decision that has already been made. Reinforcement needs to occur or the adopter may discontinue use of the innovation.

The process of diffusion of innovation through communication channels over time in a social system can be influenced by members of the social system. Potential for innovation adoption may be assessed using the innovation decision model. The first three stages of the five-stage model include thinking and decision-making processes. The decision of key stakeholders to adopt an innovation is dependent on the level of knowledge and current nature of the evidence or research supporting the innovation. Additionally, factors related to the innovation itself, organization, environment, and individuals expected to change all must be assessed in the persuasion stage. If the decision has been made to adopt an innovation, confirmation of the adoption and the benefits of the adoption must be relayed to those involved to reinforce continued innovation use.

Application of the Theory in Practice. Goodroad, Wright, and Rhame (2010) described the use of the Rogers' diffusion of innovation theory in an evidence-based practice change project. The theory was used to successfully implement a practice innovation related to renal health into two HIV clinic settings with statistically significant results.

Other recent use of the diffusion of innovations model has been successful in assessing potential for and adoption of agricultural innovations (Rogers, 2004), HIV/AIDS prevention (Vaughan, Rogers, Singhal, & Swalehe, 2000), and work-site AIDS programs (Backer & Rogers, 1998).

Summary Examine multiple middle range theories to guide the development of evidence-based practice. Utilize appropriate theories to obtain higher quality planned change

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project outcomes. Use middle range planned change theories as they study the best ways to implement, manage, and evaluate change in our ever increasingly complex health system. Disseminate new practice knowledge widely to increase nursing's practice knowledge base. New practice knowledge from planned change projects can improve the quality of nursing services provided to the public and may lead to improved population and individual health outcomes.

Critical Thinking Exercises Use the following case study to answer the critical thinking questions.

Andrea, a 16-year-old white, high school student from an upper middle class family, is ambivalent about getting the Gardasil vaccine. She is interested in boys but does not date anyone in particular and has never been sexually active. She is a cheerleader and plays tennis at her high school where she excels in her class work. She is a Christian and active in the local Young Life group at her school and attends an evangelical free church. Her parents are not encouraging her to get the shots, as they think it will promote promiscuity, but one of her friends' mothers is very vocal about “all of the girls” getting the vaccine. Andrea's mother has a history of breast cancer but not cervical cancer. She does have an aunt with a history of cervical cancer. As far as she knows, no close relatives have ever had a case of venereal warts. She has little information about HPV or cervical cancer, except that she is basically afraid of cancer as she saw its effects on her grandfather when he slowly died of lung cancer. She has seen several commercials about getting the Gardasil shots while searching the web. She has communicated with her Christian and secular friends who are talking about or have gotten the Gardasil shots to protect against HPV. Her nurse practitioner recommended it the last time she was in the clinic for her annual exam.

1. Choose one of the change theories presented in the chapter to help you analyze the case study.

What is the likelihood that Andrea will opt for the Gardasil series of shots?

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How could you, as a nurse, influence Andrea's behavior? How could you change Andrea's behavior and also help change the behavior of her friends?

2. Use the individual concepts within the change theory you chose to predict what will happen if all conditions remain the same in the scenario.

3. Choose another change theory that was presented in the chapter and prescribe a planned change project that could affect not only an individual behavioral change but a population-based change in the target population.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise for the theory of change.

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American Association of Colleges of Nursing. (2011). The essentials of master's education in nursing. Retrieved from http://www.aacn.nche.edu/education- resources/MastersEssentials11.pdf

American Association of Colleges of Nursing. (2013). Competencies and curricular expectations for clinical nurse leader education and practice. Retrieved from http://www.aacn.nche.edu/cnl/CNL- Competencies-October-2013.pdf

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211.

Backer, T., & Rogers, E. (1998). Diffusion of innovations theory and work-site AIDS programs Journal of Health Communication, 3(1), 17–28.

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Becker, M. H., & Maiman, L. A. (1975). Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 13(1), 10–24.

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Côté, F., Gagnon, J., Houme, P. K., Abdeljelil, A. B., & Gagnon, M. (2012). Using the theory of planned behaviour to predict nurses' intention to integrate research evidence into clinical decision‐making. Journal of Advanced Nursing, 68(10), 2289–2298.

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Finnell, D., & Osborne, F. (2006). Stages of change for psychotropic medication adherence and substance cessation. Archives of Psychiatric Nursing, 20(4), 166–174.

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Grove, S. K., Burns, N., & Gray, J. R. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence. St. Louis,

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Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48.

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Rogers, E. (2003). Elements of diffusion. Diffusion of Innovations, 5, 1–38.

Rogers, E. (2004). A prospective and retrospective look at the diffusion model. Journal of Health Communication, 9(1), 13–19.

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Smith, M., & Parker, M. (2015). Nursing theory and the discipline of nursing. In M. C. Smith & M. E. Parker (Eds.), Nursing theories and nursing practice (4th ed., pp. 3–18). Philadelphia, PA: F.A. Davis.

Thomas, T. L., Strickland, O. L., DiClemente, R., Higgins, M., Williams, B., & Hickey, K. (2013). Parental Human Papillomavirus Vaccine Survey (PHPVS): Nurse-led instrument development and psychometric testing for use in research and primary care screening. Journal of Nursing Measurement, 21(1), 96–109.

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Vaughan, W., Rogers, E., Singhal, A., & Swalehe, P. (2000). Entertainment-education and HIV/AIDS prevention: A field experiment in Tanzania. Journal of Health Communication, 5(suppl. 1), 81–100.

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19 The AACN Synergy Model

Sonya Hardin

Definition of Key Terms

Health care system The health care system acts as a facilitator or conduit to support patient needs and the power to nurture the professional practice environment of the nurse.

Nurse competencies The eight competencies of nursing practice as defined by the model are clinical judgment, caring practices, advocacy/moral agency, response to diversity, clinical inquiry, facilitator of learning, collaboration, and systems thinking.

Patient characteristics Eight patient characteristics have been identified that span a continuum of health to illness: vulnerability, resiliency, stability, complexity, predictability, resource availability, participation in care, and participation in decision making.

Optimal patient outcomes Patient outcomes include patient satisfaction with care, levels of trust, patient behavior and knowledge, patient functional change, and quality of life.

Introduction 617

The American Association of Critical Care Nurses (AACN) has established a vision to create a health care system that is driven by the needs of patients and families where nurses can make optimal contributions in the delivery of care. This vision involved the development of a model that explicates the practice that nurses contribute at the bedside. The model developed was the AACN Synergy Model. The goal of this model was to clearly articulate the competencies brought to patient care by nurses in meeting the needs of patients and families.

Historical Background During the early 1990s, the AACN Certification Corporation strategically set forth a direction to identify a model that described practice. In 1993, the AACN Certification Corporation, the certifying body of the AACN, established a think tank to draft a document that identified the concepts of nursing practice, most specifically certified practice. The think tank identified 13 patient needs and 9 nurse characteristics. Then, in 1995, the AACN Certification Board identified a group of “Subject Matter” experts from across the United States to refine the conceptual model. A revision to the model resulting in eight nurse characteristics and eight patient characteristics occurred.

In February 2003, the Practice Analysis Task Force expanded the assumption to the model to include the following:

The nurse creates the environment for the care of the patient. The context/environment of care also affects what the nurse can do. There is interrelatedness between impact areas. The nature of the interrelatedness may change as the function of experience, situation, or setting changes. The nurse may work to optimize outcomes for patients, families, health care providers, and the health care system/organization. Nurses bring their background to each situation, including various levels of education/knowledge and skills/experience (Practice Analysis Task Force, 2003).

In March 1996, the AACN Certification Corporation appointed an Outcome Think Tank who identified six major quality indicators: (a) patient and family satisfaction, (b) rate of adverse incidents, (c)

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complication rate, (d) adherence to the discharge plan, (e) mortality rate, and (f) the patient's length of stay (Hardin, 2005). Outcomes derived from the eight patient characteristics include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes derived from the eight nursing competencies include physiological changes, the presence or absence of complications, and the extent of treatment objectives that were obtained (Curley, 2003). Outcome data derived from the health care system include readmission rates, length of stay, and cost utilization per case.

Description of the Theory of Synergy Model

Assumption of the Model The Synergy Model is based on the following five assumptions:

“(1) Patients are biological, social and spiritual entities who present at a particular developmental stage. The whole patient (body, mind, and spirit) must be considered. (2) The patient, family, and community all contribute to providing a context for the nurse-patient relationship. (3) Patients can be described by a number of characteristics. All characteristics are connected and contribute to each other. Characteristics cannot be looked at in isolation. (4) Nurses can be described on a number of dimensions. The interrelated dimensions paint a profile of the nurse. (5) A goal of nursing is to restore a patient to an optimal level of wellness as defined by the patient. Death can be an acceptable outcome in which the goal of nursing care is to move a patient toward a peaceful death” (AACN, 2000, p. 5).

Definition of Theoretical Concepts There are totally 16 concepts in this model: eight patient concepts and eight nursing concepts (Tables 19.1 and 19.2). The concepts (characteristics) are descriptors that describe the patient and nursing. The

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eight concepts used to understand patients are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The eight concepts (characteristics) used to describe the practice of nursing are clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitator of learning. The patient and nurse characteristics are leveled from 1 to 5 and are presented in Tables 19.1 and 19.2.

Table 19.1 Patient Characteristics and Levels

Source: Adapted from AACN Certification Corporation. (2000). The AACN Synergy Model for Patient Care. Retrieved September 27, 2014, from http://www.aacn.org/wd/certifications/content/synmodel.pcms?

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Table 19.2 Nurse Characteristics and Levels

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Source: Adapted from AACN Certification Corporation. (2000). The AACN Synergy Model for Patient Care. Retrieved September 27, 2014, from http://www.aacn.org/wd/certifications/content/synmodel.pcms? menu=certification#Assumptions

Patient characteristic levels are based on a five-point Likert scale, ranging from 1 (the worst patient state) to 5 (the best patient state). Nurse characteristic levels are based on a five-point Likert scale with 1 being novice and 5 being expert. Descriptions of levels 1, 3, and 5 have been described by the AACN. Levels 2 and 4 have not been specifically identified in the literature by the AACN. However, the use of the five levels with levels 1, 3, and 5 as benchmarks has been useful to nursing organizations as they develop clinical ladders. Further work has been completed on the nurse characteristics for the advanced-practice role (Becker et al., 2006). Activities of advanced-practice nurses organized by the eight nurse characteristics emerged through a study of practice

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conducted by the AACN Certification Corporation. While some of these activities overlap with the expert nurse, the study identified four nurse characteristics considered most critical by clinical nurse specialists (clinical judgment, caring practices, facilitator of learning, and clinical inquiry) and two activities most critical by nurse practitioners (clinical judgment and advocacy/moral agency) (Becker et al., 2006).

Patient Characteristics Each patient brings a unique set of characteristics to the health care situation. Among many characteristics that are present, eight are consistently seen in acute and critically ill patients. These eight characteristics are consistently assessed by nurses in variable levels given each patient situation. They should be assessed in the patient as well as other patterns that are unique to the given circumstances of the patient. Resiliency is the patient's capacity to return to a restorative level of functioning using compensatory coping mechanisms. The level of resiliency is often dependent upon the patient's ability to rebound after an insult. This ability can be influenced by many factors including age, comorbidities, nutritional status, and compensatory mechanisms that are intact. Vulnerability is the level of susceptibility to actual or potential stressors that may adversely affect patient outcomes. Vulnerability can be impacted by the patient's physiological/genetic make-up or health behaviors exhibited by the patient, such as risk factors. Stability refers to the patient's ability to maintain a steady state of equilibrium. Response to therapies and nursing interventions can impact the stability of the patient. Complexity is the intricate entanglement of two or more systems. Systems refer to either physiological or psychological states of the body or family dynamics or environmental interactions with the patient. The more systems involved, the more complex are the patterns displayed by the patient. Resource availability is influenced by the extent that resources are brought to the context by the patient, family, and community. The resources can present as pharmaceutical, technical, fiscal, personal, psychological, social, or supportive in nature. A greater potential for a positive outcome exists when a patient has more resources. Participation in care is the participation by the patient and the family who are engaged in the delivery of care. Patient and family participation can be influenced by health status, educational background, health literacy, resource availability, and cultural background. Participation in decision making is the level of engagement

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of the patient and the family in comprehending the information provided by health care providers and acting upon this information to execute informed decisions. Patient and family engagement in clinical decisions can be impacted by the knowledge level of the patient, his or her capacity to make decisions given the insult, cultural background (i.e., beliefs and values), and the level of inner strength during a crisis (AACN Certification Corporation, 2002).

Nurse Characteristics The nurse characteristics can be considered competencies that are essential for providing care to the acute and critically ill. All eight competencies reflect an integration of knowledge, skills, and experience of the nurse. The competencies include clinical judgment, advocacy, caring practices, systems thinking, facilitation of learning, collaboration, response to diversity, and clinical inquiry. Clinical judgment is the clinical reasoning that is used by a health care provider in the delivery of care. It consists of critical thinking and nursing skills that are acquired through a process of integrating formal and experiential knowledge. The integration of knowledge and experience brings about the clinical decisions made during the course of care for patients, groups, and communities. Advocacy is working on another's behalf when the other is not capable of advocating for himself or herself. The nurse serves as a moral agent in identifying and helping to resolve ethical dilemmas within the clinical setting. Caring practices are the constellation of nursing interventions that are unique to the needs of the patient and the family. Caring behaviors include compassion, vigilance, engagement, and responsiveness to the patient and the family. Collaboration is the nurse working with others to promote optimal outcomes. The patient, family, and members of various health care disciplines collaborate by working toward promoting the needs and requests of patients. Systems thinking is the tool and knowledge that the nurse uses to recognize the interconnected nature within and across the health care system. The ability to understand how one's decision can impact the whole is integral to systems thinking. The nurse uses a global perspective in analyzing problems, making decisions, and negotiating for the patient and the family internally and externally to the health care system. Response to diversity is the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Nurses need to recognize the individuality of each patient while observing for patterns that

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respond to nursing interventions. Nurses should be open to the patient's spiritual beliefs, ethnicity, family configuration, lifestyle values, and the use of alternative and complementary therapies. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. Clinical inquiry evolves as the nurse moves from novice to expert. At the expert level, the nurse enhances, deviates, and/or individualizes standards and guidelines to meet the needs of patients, families, groups, and communities. Facilitator of learning is understood as the nurse facilitating learning among patients, families, communities, and staff through tailored educational programs. The educational level of the audience should be considered in the design of the plan to educate. Creative methods should be developed to ensure patient and family comprehension and to make informed decisions. Each nurse and patient characteristic is understood on a continuum from 1 to 5. The level of each patient characteristic is critical in identifying the competency required of the nurse (AACN Certification Corporation, 2002).

Research The Synergy Model is useful in identifying optimal patient outcomes given evidence-based nursing interventions (Kaplow & Hardin, 2007). Optimal outcomes can be measured through the use of numerous instruments. For example, as the nurse begins managing the transition of the patient from one setting to another, the outcome of transition without complications is established. The nurse can use numerous research-developed risk- screening instruments to improve post discharge problems. Or, if the nurse is managing an organ donor, pathways have been developed by the United Network for Organ Sharing to guide the decisions and actions in managing donors. Such pathways have been researched and/or reached through clinical consensus (Kaplow & Hardin, 2007).

Evidence-based practice is based upon clinical inquiry of scientists in the field or developed protocols through clinical evidence. The integration or the translation of research findings into practice is a characteristic of clinical inquiry. The tools evolved from evidence-based practice and hence clinical inquiries have supported the decision making of nurses. Through evidence-based practice, interventions and outcomes can be identified. See Box 19.1 for the role of the Synergy Model and decision making in

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evidence-based practice.

BOX 19.1 The Synergy Model and Decision Making in Evidence-Based Practice

A physiological change in a patient warrants the matching of patient needs with nurse competencies to ensure the patient's safe passage during an acute episode.

Nurses should identifies patient attributes and plan care using nurse characteristics that meet both the immediate needs of the acute insult as well as supports desired outcomes through the recovery process.

Nurses provide interpretation of clinical data, treatments, and evaluation of responses to interventions individualized to the patient through synergy

Nurses demonstrate competencies in clinical judgment and collaboration for the highly complex patient who is vulnerable and unpredictable.

Nurses are capable of preserving the patient's dignity, and reduce anxiety through caring practices and advocacy.

Optimal outcomes are achieved by restoring and maintaining functional status, providing emotional support, and returning the patient to a precrisis state.

Source: Arashin, K. A. (2010). Using the synergy model to guide the practice of rapid response teams. Dimension of Critical Care Nursing, 29(3), 120–124.

Further research with the model needs to be conducted to validate the model within other practice settings and patient populations. One approach is to identify questions surrounding the concepts of the model and then to identify instruments that can be utilized to measure the concepts. Table 19.3 displays four instruments that measure the patient characteristic of vulnerability. Evaluating older adults for vulnerability by measuring disability, comorbidities, and frailty are proxies for vulnerability in critical care (Hardin, n.d.). Although these instruments have not been utilized extensively within critical care settings, the potential exists to design correlational studies to evaluate vulnerability and outcomes.

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Table 19.3 Instruments for Measuring the Characteristics of Vulnerability

Studies are needed on the nursing characteristics described in the model. How these characteristics impact optimal patient outcomes will require the use of existing instruments and the design of new measurements. Table 19.4 displays instruments that can be utilized to measure the nurse characteristic of caring. A number of scales have been developed to measure caring (Beck, 1999). However, the majority of these scales have not been utilized in research studies in the setting of critical care.

Table 19.4 Instruments for Measuring the Nurse Characteristic of Caring

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Using the Synergy Model as the framework for nursing research, which is designed to examine the characteristics of the patient and the nurse, is limited in the literature. Quantitative measurement of the characteristic in descriptive studies and studies designed to test an intervention that affects the characteristics is needed to facilitate optimal patient outcomes.

Nursing Education Using the Synergy Model to facilitate the learning of patients, families, communities, and staff has been discussed in the literature (DeBourgh, 2012; Hardin, 2004; Kaplow, 2002; Zungolo, 2004). Teaching can be enhanced by using the patient and nurse competencies to design care. The patient should be analyzed through identifying data points associated with each of the patient characteristics. Nursing interventions from each of the eight nursing competencies should be chosen to address the patient characteristics. Developing courses or curriculums can be accomplished with the Synergy Model as a framework. An example of the model being used has been described as the framework for the Duquesne University School of Nursing (Zungolo, 2004). In this school, each nurse

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characteristic has been used as a thread in the undergraduate curriculum across 4 years of study. The nurse characteristic of caring practices is to be demonstrated in freshman year as care of self and caring processes, sophomore year as initiating caring practices, junior year as integrating caring into one's practice, and senior year as displaying a caring attitude in all aspects of one's practice. Table 19.5 displays the three spheres of influence for undergraduate education (DeBourgh, 2012).

Table 19.5 Synergy Model in Undergraduate Education

Source: Adapted from DeBourgh, G. A. (2012). Synergy for patient safety and quality: Academic and service partnerships to promote effective nurse education and clinical practice. Journal of Professional Nursing, 28(1), 48–61.

The Synergy Model has been used to revise and update critical care graduate programs such as the one provided by Marymount University in Arlington, VA, to prepare clinical nurse specialists (Cox & Galante, 2007). The eight nurse competencies became the framework for the courses with the instructor preparing a lecture on each competency and then a seminar focused on specific content areas that could be discussed in relationship to the content. For example, during week 6, the instructor provided a lecture on collaboration and then had content in the seminar on hypovolemic shock, acute inflammatory diseases, and dysrhythmias. The clinical component of the course ensured integration and application of the Synergy Model as students were expected to learn the role of the critical care clinical specialist and to apply the eight nursing characteristics. The students used the nurse characteristics in a journal for reflecting on the experiential knowing of working in the role of a clinical nurse specialist (Cox & Galante, 2007).

The Synergy Model can be used as a blueprint in staff development within clinical facilities. It is used to facilitate acquisition of knowledge, skills, and values across a nursing career (Green, 2006). The model will enhance the teaching–learning process and outcomes for nurse educators, learners, and the system. Green (2006) discusses the reorganization of characteristics relative to the learner to include five of the AACN Synergy

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Model Characteristics assigned to the patient: resiliency, vulnerability, resource availability, participation in learning and decision making, and predictability. All the educator competencies are the same as the nurse characteristics. When the needs of the learner are matched with the educator characteristics, then learning outcomes are improved.

Nursing Practice The Synergy Model is a model of practice. Practice is driven by the characteristics and needs of the patient. Nurses respond to the needs of the patient through nurse characteristics. When the patient and nurse characteristics are matched to facilitate optimal outcomes, synergy occurs (Pacini, 2005). The eight nursing competencies represent nursing practice. However, the core of nursing is clinical judgment, which is grounded in the nursing process of assessment, planning, intervention, and evaluation. Making decisions to act or not act is intervention. These decisions come about through the integration of knowledge and critical thinking skills such as distinguishing relevant data from the irrelevant, recognizing patterns and relationships, determining desired outcomes, and continuously evaluating.

Advocacy is doing for patients that which they cannot do so for themselves in that they lack the knowledge or ability due to alteration in physiological systems. Nurses advocate through their pursuit of supporting the patient's right to self-determination and autonomy and being a “protective shield” when the client is unable to advocate for oneself (Hanks, 2005, p. 76).

The characteristic of caring practices includes interventions of spiritual support for end of life (Levey, Danis, Nelson, & Solomon, 2003), promotion of a “healing environment” (Smith, 2006, pp. 44, 45), and the use of listening and therapeutic communication skills. Nurses intervene by providing an unconditional positive regard and nonjudgmental stance toward the patient and creatively using self to engage in healing practices (Hardin & Kaplow, 2005).

Given the increasing complexity required in the care of patients, collaboration is a critical nurse characteristic. Individuals collaborating together are successful when (a) there is a compelling, shared drive or goals; (b) individuals with unique competencies will contribute to successful outcomes; (c) members operate within a formal structure, with

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defined roles that facilitate collective/collaborative work; and (d) there is mutual respect, tolerance, and trust. Individuals must be willing to take on different roles within a group and be honest and open with their ideas and concerns. There are times when an individual should be a follower and when that person should be a leader.

Systems thinking is used to address the most challenging patient and organizational problems in health care. This nurse characteristic allows one to understand reality through the relationships among the system's parts, rather than the parts themselves. Long-term ramifications from a decision and a more accurate picture of reality, so that you can work with a system's natural forces, allow achievement of results desired.

Response to diversity is a characteristic that requires the nurse to approach each situation with an open mind and the ability to use respect when faced with requests or practices that are not understood. Providing culture-specific care is a stance that promotes healing. Nurses must first examine their own biases and values while providing sensitive care to others. To understand another, the nurse must seek knowledge about that person's culture. Assessing the needs of the patient and the family requires the skill of obtaining relevant cultural data to promote optimal patient outcomes (Campinha-Bacote, 2011).

Questioning to uncover best practices or innovative strategies to meet the needs of patients and families is a form of clinical inquiry. “Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice based on available data, and innovating through research and experiential learning” (Curley, 2003, p. 66). Nurses must remain knowledgeable of the new scientific information for applying the best research evidence while respecting the patient's and family's values (Jayadevappa & Chhatre, 2011).

Facilitator of learning is a characteristic that uses “teaching moments” throughout the time care is provided. Strategies to improve outcomes require the nurse to educate patients and families. Besides patients and families, nurses must continually work with new nurses who arrive on the unit as orientees. Psychomotor, critical-thinking, and clinical decision- making skills are role modeled, taught, and facilitated (Kaplow, 2002). Whether the nurse is working with a new orientee or patients and families, taking the lead in providing the knowledge and skills for the delivery of care is an aspect of this competency.

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Use of the Theory in a System Clarian Health Partner is the first hospital system in the United States to integrate the AACN Synergy Model for Patient Care in an organization. Nurses hired into the system are as an associate partner, partner, or senior partner. These three levels correlate with the three levels of the nurse characteristics and differentiated practice principles (Kerfoot, 2004). In this organization, the model is used to simplify the needs of the patient. From the orientation of the nurse, to the clinical ladder, to job descriptions and documents, the model provides the framework for this organization. The integration of this model into an organization is an exemplary example of advancing accountability and professionalism in the workplace (Kaplow & Hardin, 2007).

The Synergy Model is being utilized nationally in hospitals on the journey to magnetism (Kaplow & Reed, 2008). (See examples of the use of the middle range theory in research and for practice in Using Middle Range Theory in Practice 19.2 and Using Middle Range Theory in Research 19.3.) A professional model of practice is a requirement for magnet designation. The model must be integrated throughout the system and guide improvement in outcomes. A major step in the process is to embrace the model by designing job descriptions and clinical ladders that promote clinical advancement. This will require staff nurses and leadership of an organization to reach consensus on the level of integration of the model into expectation of job performance.

USING MIDDLE RANGE THEORY IN PRACTICE 19.2

Source: Kohr, L. M., Hickey, P. A., & Curley, M. A. Q. (2012). Building a nursing productivity measure based on the synergy model: First steps. American Journal of Critical Care, 21(6), 420–430.

Problem This study developed indicators that can be utilized to measure each

of the patient characteristics in a typical ICU patient. The development of a patient assignment tool included using indicators for a patient that

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is easy, typical, or hard to provide nursing care. An easy patient is one who has stable vital signs, needs routine care, tolerates procedures, is on target for recovery, has stable home environment, and has extended family resources. A difficult patient would have a direction of illness that reflects compilations, numerous interventions, many invasive catheters, a number of multiple diagnosis, complex technologies, and a lack of reserve.

Nursing Interventions An example of a “hard patient” would be a 67-year-old frail female

who had been rehabbing in a long-term care facility and was found unconscious by a nursing assistant. She has a history of hypertension, breast cancer, thrombocytosis, peripheral vascular disease, osteoporosis, parietal stroke, normo-progressive hydrocephalus, and mild emphysema. Upon entering the emergency department, she had a Foley catheter inserted that had a thick milky return. A CBC revealed a WBC of 56,000. IV fluids were started, and she was transported to the ICU. Her blood pressure was 62/34. She was cool to touch and was having difficulty maintain her O2 saturation on a rebreather mask. A decision was made to intubate after ABGs showed respiratory acidosis. An arterial line was inserted. Her blood pressure required pressure support, and the EKG showed dysrhythmias. This patient was receiving 1:1 nursing care due to the intensity of care needs. This patient was a “hard patient” due the multiple diagnoses, numerous interventions, and a lack of reserve.

Conclusions/Outcomes Utilizing the patient assignment tool described in this research

article would support the assignment of a 1:1 nurse-to-patient ratio. Such tools are needed to ensure that the needs of the patient drive the nursing care.

USING MIDDLE RANGE THEORY IN RESEARCH 19.3

Source: Magee, M. F., Nassar, C. M., Copeland, J., Fokar, A., Sharretts,

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J. M., Dubin, J. S., & Smith, M. S. (2013). Synergy to reduce emergency department visits for uncontrolled hyperglycemia. The Diabetes Educator, 39(3), 354–364.

Research Purpose The purpose of this pilot study was to evaluate the safety and

preliminary efficacy of a treatment algorithm and education intervention for the management of patients with type 2 diabetes mellitus (T2DM) and hyperglycemia presenting to the emergency department (ED) and stable enough to be discharged home.

Research Design A prospective, nonrandomized pilot intervention with historic self-

controls.

Sample/Participants Urban hospital ED patients (n = 86) with BG ≥ 200 mg/dL were

enrolled.

Data Collection Data was collected from subjects with hyperglycemia who received

follow-up visits at 72 hours, 2 and 4 weeks, and 6 months. A management algorithm was utilized along with a self-management education program during visits..

Findings Participants were 51.8% male and 92% black, and 87.3% had

private or public insurance. The top reasons for presenting to the ED were no provider appointment available (41.7%) and no primary care provider (14.6%). No hypoglycemia occurred in the first 24 hours following ED T2DM medication initiation or titration, and overall hypoglycemia rates were low. BG was reduced from 356 ± 110 mg/dL at baseline to 183 ± 103 mg/dL at 4 weeks (p < 0.001).

The use of the Synergy Model to guide the multidisciplinary intervention significantly reduced blood glucose at 4 weeks.

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Summary The Synergy Model resonates with clinicians because it describes a practice where nurses achieve optimal patient outcomes with patients and families. The mutuality and reciprocal nature of the relationship between nurses and patients are unique and central to the Synergy Model. The nurse is the one constant in the trajectory of disease that has the ability to detect subtle changes due to the intense length of care over time. The use of the Synergy Model enhances the nurse's understanding of the contribution that is brought to the patient and the family through the discipline of nursing.

Critical Thinking Exercises

1. In today's health care environment, how is it possible to attempt to match patient characteristics to specific nurse competencies in order to optimize patient outcomes?

How is this accomplished in the acute care setting? How is this accomplished in the long-term care setting?

2. Apply the Synergy Model to a patient scenario that you have been the care provider.

3. Redesign SBAR to reflect the Synergy Model. 4. Design a job description that utilizes the Synergy Model as the

framework.

Resources on Visit http://thePoint.lww.com/Peterson4e for helpful web resources and an Analysis of Theory exercise to critique the Synergy Model.

REFERENCES

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http://thePoint.lww.com/Peterson4e

AACN. (2000). Assumptions Guiding the AACN Synergy Model for patient care. Retrieved September 27, 2004, from http://www.aacn.org/wd/certifications/content/synmodel.pcms? menu=certification#Assumptions

AACN Certification Corporation. (2002). The AACN Synergy Model for patient care. Retrieved July 2014, from http://www.aacn.org/wd/certifications/content/synmodel.pcms? menu=certification

AACN Practice Analysis Task Force. (2003). History of AACN Certification Corporation. Retrieved July 2014, from http://www.aacn.org/wd/certifications/content/aboutus.pcms? menu=certification

Beck, C. T. (1999). Quantitative measurement of caring. Journal of Advanced Nursing, 30(1), 24–32.

Becker, D., Kaplow, R., Muenger, M., & Hartigan, C. (2006). Activities performed by acute and critical care advanced practice nurses. American Journal of Critical Care, 15(2), 130–148.

Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. The Online Journal of Issues in Nursing, 16(2), Manuscript 5.

Cox, C., & Galante, C. (2007). An MSN curriculum in preparation of CCNSs: a model for consideration. Critical Care Nurse, 23(6), 74–80.

Curley, M., Danus, M., Nelson, J., & Soloman, M. (2003). Quality Indicators for end of life in the intensive care unit. Critical Care Medicine, 31, 2255–2262.

DeBourgh, G. A. (2012). Synergy for patient safety and quality: Academic and service partnerships to promote effective nurse education and clinical practice. Journal of Professional Nursing, 28(1), 48–61.

Green, D. A. (2006). A synergy model of nursing education. Journal for Nurses in Staff Education, 22(6), 277–283.

Hanks, R. G. (2005). Sphere of nursing advocacy model. Nursing Forum, 40(3), 75–78.

Hardin, S. R. (2004). Using the synergy model with undergraduate students. Excellence in Nursing Knowledge. Retrieved July 2014, from http://www.nursingknowledge.org/Portal/main.aspx? pageid=3507&ContentID=56388

Hardin, S. R. (2007). Vulnerability of older adults in critical care. Critical Care Nurse.

Hardin, S. R., & Kaplow, R. (2005). Synergy for clinical excellence: The AACN Synergy Model for patient care. Sudbury, MA: Jones & Bartlett.

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http://www.aacn.org/wd/certifications/content/synmodel.pcms?menu=certification

http://www.aacn.org/wd/certifications/content/aboutus.pcms?menu=certification

http://www.nursingknowledge.org/Portal/main.aspx?pageid=3507&ContentID=56388

Kaplow, R. (2002). Applying the Synergy model to nursing education— The synergy model in practice. Critical Care Nurse, 22(3), 77–81.

Kaplow, R., & Hardin, S. R. (2007). Critical care nursing: Synergy for optimal outcomes. Sudbury, MA: Jones & Bartlett.

Kaplow, R., & Reed, K. D. (2008). The AACN Synergy Model for patient care: A nursing model as a force of magnetism. Nursing Economics, 26(1), 17–25.

Kerfoot, K. (2004). Synergy from the vantage point of a chief nursing officer. Excellence in Nursing Knowledge. Retrieved July 2014, from http://www.nursingknowledge.org/Portal/main.aspx? pageid=3507&ContentID=56442

Jayadevappa, R., & Chhatre, S. (2011). Patient centered care—A conceptual model and review of the state of the art. The Open Health Services and Policy Journal, 4, 15–25.

Levey, M., Danis, M., Nelson, J., & Solomon, M. Z. (2003). Quality indicators for end-of-life in the intensive care unit. Critical Care Medicine, 31, 2255–2262.

Pacini, C. M. (2005). Synergy: A framework for leadership development and transformation. Critical Care Nursing Clinics of North America, 17(2), 113–119, ix.

Smith, A. R. (2006). Using the synergy model to provide spiritual care in critical care settings. Critical Care Nurse, 26(4), 41–47.

Zungolo, E. H. (2004). The synergy model in educational practice: A guide to curriculum development. Excellence in Nursing Knowledge. Retrieved July 2014, from http://www.nursingknowledge.org/Portal/main.aspx? pageid=3507&ContentID=56394

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http://www.nursingknowledge.org/Portal/main.aspx?pageid=3507&ContentID=56394

APPENDIX Instruments

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Index

A AACN Synergy Model. See Synergy Model Abstract concepts Abstractness Action

commitment to plan of simultaneous

Action-oriented strategies Activity-related affect Acute pain management Adaptation

in Modeling and Role-Modeling (MRM) Roy's model

Adaptive equilibrium Adaptive Potential Assessment Model (APAM) Adequacy Adolescent Resilience Model (ARM) Advanced practice psychiatric nurse (APPN) Adverse conditions Advocacy Aesthetic knowing Affective empathy Affiliated-individuation American Association of Critical Care Nurses (AACN) Synergy Model.

See Synergy Model Analgesia Anxiety Anxious ambivalence Anxious avoidance Appraisal support Armstrong model of symptom experience Arousal Assessment

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functional pain and side effects

Assisted Living (AL) communities Attachment, basic needs and Attachment theory

applications of practice research

as basic need care index in and cure definition of description of development and change future research and health historical background on internal working models key terms in patterns

anxious ambivalence anxious avoidance disorganized attachment earned secure secure attachment

Automatic nursing process Awareness, communication in

B Barnum's theory evaluation recommendations Barthel Index (BI) Basic Need Satisfaction Inventory Behavioral specificity Being with (definition) Bidirectional support Blocking Bone health Boundaries of resilience Breast-feeding and infant care

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Brief Fatigue Inventory Burke/Eakes Chronic Sorrow Assessment Tool

C Cancer care Care

index Care Satisfaction Questionnaire (CARE/SAT) Caring. See also Theory of Caring

definition of key terms in Model practices

The Caring Ability Inventory (CAI) Caring Assessment Report Evaluation Q-sort (CARE-Q) Caring Behavior Assessment Tool (CBA) Caring Behavior Checklist (CBC) Caring Behavior Inventory (CBI) The Caring Behavior of Nurses Scale (CBNS) Caring Dimension Inventory (CDI) Caring–healing profession Caring Mate/Caring Other Scale Carper's ways of knowing Causality Causal propositional statements Charlson Comorbidity Index (CCI) Chronic Respiratory Disease Questionnaire (CRDQ) Chronic sorrow

definition research theory See (Theory of Chronic Sorrow)

Clarian Health Partner Clarity

communication in Client-centered nursing theory Clinical decision making Clinical inquiry Clinical judgment Cochrane database

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Coding system Cognitive empathy Cognitive performance Cognitive strategies Cold therapy Collaboration Collector Colostomy Comfort

interventions needs taxonomic structure of

Comfort Behaviors Checklist (CBC) ComfortPlace™ Comfort Theory

concepts, propositions applications of

practice research

definitions of description of theory in empirical testing instruments for

Comfort Behaviors Checklist (CBC) General Comfort Questionnaire (GCQ) Healing Touch Comfort Questionnaire (HTCQ) Hospice Comfort Questionnaire (HCQ) Radiation Therapy Comfort Questionnaire (RTCQ) Urinary Incontinence and Frequency Comfort Questionnaire

(UIFCQ) verbal rating scales

historical background on key terms in theoretical framework for

Commitment to plan of action Communication

awareness, clarity, and continuity in in Theory of Interpersonal Relations

Competition Complexity Computer-assisted approach

653

Concept Conceptual models

controversy in definition development of uses

Concrete concepts Conflict Consistency Continuity in communication Correlational prepositional statements Counselor, nurse role as Counselor Rating Scale Counting on others (psychological tasks) Couples Miscarriage Healing Project Crittenden's sensitivity scale Cronbach's alpha Cultural and nursing care competence Culturally Specific Africentric Relaxation Exercise Cure and attachment theory

D Deconstructionists Deduction Delaying satisfaction (psychological tasks) Deliberative Nursing Process

applications of in group context in measuring nursing outcomes in practice setting with prospective nursing students in research in theory development

assumptions and propositions definition of theory concepts

automatic nursing process deliberative nursing process dynamic nurse–patient relationship immediate need for help

654

nursing situation patient distress patient outcomes/product validation

description of function of nursing major components and relationships simple yet complex

empirical testing instruments pain and distress instrument safety agreement instrument

historical background on defining nursing and outcome variables Orlando's legacy

key terms in research applications in

culturally competent care, delivering diverse range of ethical care of older adults nursing informatics

Developmental philosophy Direct care worker (DCW) performance Direct indicators Discipline Discrimination Disorganized attachment Disparity Doing for (definition) Domain Dynamic nurse-patient relationship

E Early interaction Earned secure Ease Educational resilience Ego-resilience Emotional care Emotional support

655

Empirical adequacy Empirical knowing Empirical testing, instruments. See Instruments, empirical testing Empiricism Empowerment Program on self-care Enabling (definition) Enactive attainment Environment

definition of concept and policies, evaluation of in Theory of Interpersonal Relations

Environmental comfort Epidural analgesia Epigenetic Epistemology Erickson Maternal Bonding Attachment Tool Ethical knowing Ethical values in care of older adults Ethicists Ethics Evidence-based practice Exercise Benefits/Barriers Scale (EBBS) Exercise, self-efficacy for Expectancy-value theory Expected outcomes Exploitation phases External criticism External management methods

F Facilitation Facilitator of learning Fall prevention, self-efficacy for Fawcett's metaparadigm Fawcett's theory evaluation recommendations Fear of falling Ferrans and Powers QOL Index Five-factor personality inventory (FFPI) Formal support

656

The Frailty Index The Frailty Trait Scale Frustration Functional performance Function-Focused Care in Assisted Living intervention

G General Comfort Questionnaire (GCQ) Generic tools Global tools Good outcomes Grand theory

H Healing Touch Comfort Questionnaire (HTCQ) Health

and attachment theory behaviors, self-efficacy and defined by Pender definition of concept in Theory of Interpersonal Relations

Health Belief Model (HBM) application of theory description of theory

Health care facilities system

Health promoting behavior Health-promoting lifestyle Health promotion Health Promotion Model (HPM)

for clinical practice model selection in in tailoring nursing interventions

description of empirical testing instruments health promotion in

657

historical background on Pender's definition of health theoretical propositions of

Health-Related Quality of Life (HRQOL) applications of definition of theory concepts description of empirical testing instruments in

categories of measurement guidelines for measurement

historical background on key terms in nursing process and the dimensions of outcome measure in nursing

Health-seeking behaviors (HSB) Health/well-being Hertz Perceived Enactment of Autonomy Scale (HPEAS) Holarchy of nursing knowledge Holism Holistic Caring Inventory (HCI) Horizontal relationship Hospice Comfort Questionnaire (HCQ) Hospital Anxiety and Depression Scale Hospital Consumer Assessment of Healthcare Providers Service

(HCAHPS) Human Experience of Miscarriage Model

I Identification phases Identifying oneself (psychological tasks) Immediate competing demands/preferences Immediate emotional response Immediate need for help Indirect indicators Induction Inductive approach Informal support Informational support Inherent endowment

658

Inner Core Child Resilience Model Inspiratory muscle strength (IMS) Inspiratory muscle training (IMT) Institutional integrity (InI) Instrumental support Instruments

empirical testing in Comfort Theory See also (under Comfort Theory) in Deliberative Nursing Process in Health Promotion Model Health-Related Quality of Life (HRQOL) for Resilience in Theory of Unpleasant Symptoms (TOUS)

for measuring characteristics of caring for measuring characteristics of vulnerability for Modeling and Role-Modeling (MRM) for testing Theory of Interpersonal Relations

Integrated prescriptive approach Interactive–integrative paradigms Internal criticism Internal management methods Internal working model Interpersonal influences Interpersonal relations, 263. See also Theory of Interpersonal relations

definition of Interpersonal Relationships Inventory (IPRI) Intervening variables Interviewer

J Jaw relaxation Johnson's Behavioral System Model

K King's Theory of Goal Attainment Knowing (definition) Knowledge

659

development nursing See (Nursing knowledge) workers

Kolcaba's theory evaluation recommendations Kuhn on paradigm

L LaCoursiere's theory Leader, nurse role as Leininger's Theory of Cultural Care Diversity and Universality Lewin's theory of change Life domains Lifetime development Lifetime growth Likert-style format Logic Logical development Logical positivism Loss experience

M Maintaining belief (definition) Maladaptive equilibrium Maslows' pyramid (attachment needs) Mastery experience McGill Pain Questionnaire Meaning-based models Mechanistic philosophy Meleis' theory evaluation recommendations Memorial Symptom Assessment Scale Metaparadigm

controversy definition development Fawcett's relational and nonrelational propositions requirements uses

660

Metaphysics Metatheory Micro theory Middle range social support theory Middle range theories

cognitive in Comfort Theory from conceptual models definition and scope in Deliberative Nursing Process development emotional evaluation process examples in Health Promotion Model in Health-Related Quality of Life (HRQOL) historical background integrative key terms in Modeling and Role-Modeling (MRM) nursing research theory physiological Planned Change social theory analysis theory evaluation theory of Chronic Sorrow in Theory of Interpersonal Relations uses

Minimally clinical importance difference (MCID) Minnesota Living with Heart Failure (MLHFQ) Mixed methods research Modeling and Role-Modeling (MRM)

adaptation affiliated-individuation applications of

adaptive potential assessment model (ADAM) affiliated-individuation health/well-being other studies in

661

self-care resources/actions definitions of concepts in

related to nursing related to persons

description of paradigm for nursing practice theoretical linkages in

environment in facilitation in health in historical background on holism inherent endowment instruments used in key terms in lifetime development lifetime growth modeling in nursing in nurturance person in Person's Model of World role-modeling unconditional acceptance utilization for nursing and practice

Modeling in MRM Motivation for healthy behavior Multidimensional definitions of social support Multidimensional Scale of Perceived Social Support (MPPSS) Mutual goal setting

N Narcotics National Institute of Nursing Research (NINR) National Institutes of Health (NIH) National Quality Measures Clearinghouse ( NQMC ) NCRCS chronic sorrow instrument development Needs Negative social support

662

Negative support Neonatal Intensive Care Unit (NICU) New Mothers Network Nonpharmacological adjuvants Nonrelational statements Nonsteroidal anti-infl ammatory drugs (NSAIDs) North American Nursing Diagnosis Association (NANDA) Nottingham Health Profile Numeric Pain Intensity Scale Numeric Rating Scale Nurse characteristics Nurse competencies Nurse practitioner (NP) Nursing

assistants care definition of concept diagnosis function of informatics interventions metaparadigm in Modeling and Role-Modeling (MRM) perspectives in practice research theory situation in Theory of Interpersonal Relations

Nursing knowledge conceptual models definition grand theory key terms in metaparadigm micro theory middle range theory paradigms philosophy practice theory research vs. practice theories

663

situation-specific theories theories of nursing

Nursing metaparadigm Nursing methods to understand interpersonal processes. See under See

under Theory of Interpersonal Relations Nursing Practice Enhancement Project (NPEP) Nurturance

O Observation Ontological paradigm Ontology Opioids Optimal patient outcomes Orem's Self-care Deficit Theory Organistic philosophy Organizational change theories

Lewin's theory of change Rogers' diffusion of innovations theory

Orientation phase Orlando's legacy Outcome expectations

P Padilla and Grant model Pain

definition and distress instrument instruments for measurement of mechanisms patient teaching relief sensation

Pain (balance between analgesia and side effects) applications

additional research suggestions research support

664

heory of pain historical background

integrated prescriptive approach pain mechanism theories pain relief theories

key terms theory concepts uses

Pain-relieving medication Paradigms

controversy definition development Kuhn on for nursing practice systems of classification uses

Parsimony Participant Participating with others (psychological tasks) Participation in care Particulate–deterministic paradigms Patient Assessment Form Patient characteristics Patient cue Patient distress Patient outcomes/product Patient Reported Outcomes Measurement Information System (PROMIS)

Program Patient self-management Patient teaching on pain Patterns of attachment Pender's definition of health Peplau's theory of interpersonal relations Perceived barriers to action Perceived benefits of action Perceived enactment of autonomy (PEA) Perceived self-efficacy Perceived support Performance

665

Person(s) definition of concept in Modeling and Role-Modeling (MRM) in Theory of Interpersonal Relations

Person's Model of World Personal factors Personality Personal knowing Personal Resources Inventory Person-focused resilience research Person's Model of World Persuasive health Pharmacological adjuvants Phases of nurse–patient relationship Phenomenon Philosophers Philosophical foundation of Theory of Interpersonal Relations Philosophy

of nursing knowledge controversy development uses

Physical activity among Hispanic women, promotion of Physical comfort Physicians Physiological factors Physiological feedback Piaget's theory Planned change

definition of theory health belief model historical background key terms of organizational change theories

Lewin's theory of change Rogers' diffusion of innovations theory

theory of planned behavior transtheoretical model

Positive health research Potent pain medication

666

Power analysis Practice Practice theory/micro theory/situation specific theory Practice theory Pragmatic Primitive concepts Prior related behavior Professional support Property concepts Propositions Protective factors Proxies Proximity maintenance Psychobiological experiences

conflict frustration needs unexplained discomfort/anxiety

Psychological factors Psychological tasks

counting on others delaying satisfaction identifying oneself participating with others

Psychospiritual comfort

Q Quality-adjusted life-year (QALY) instrument Quality of life (QOL) Quality of Life Assessment Quality of Life Questionnaire

R Radiation Therapy Comfort Questionnaire (RTCQ) Randomized controlled trial (RCT) Reality convergence Reciprocity in social support

667

Recording Reflection Relational statements Relief Religion Religiosity Repeated Measures Multivariate Analysis of Variance (RM-MANOVA) Research

in attachment theory person-focused resilience positive health Synergy Model in

Research applications for attachment theory in Deliberative Nursing Process for middle range nursing theory for Pain (balance between analgesia and side effects) for self-efficacy theory of chronic sorrow

Resilience Adolescent Resilience Model in adverse conditions in applications of

instruments, evaluation of model development and guiding intervention development practice applications of theory

boundaries of cross-cultural considerations related to individual/aggregate objective/subjective psychological/physiological trait/state/process

definition of definition of theory concepts

boundaries of resilience perspectives in nursing terminology and attributes of

description of empirical testing instruments good outcomes in

668

historical background on key terms in nursing literature on specific models of

Resolution phases Resource availability Resource person, nurse role as Risk factors Robinson Self-appraisal Inventory Rogers' diffusion of innovations theory

application of definition of description of

Role in nursing Role modeling Roy's adaptation model

S Safe haven behavior Safety agreement instrument Science Scope Secure attachment Secure base behavior Self-care action Self-care knowledge Self-care Resource Inventory Self-care resources Self-efficacy theory

application, in practice application, in research

for bone health in breast-feeding and infant care for cancer care in cultural and nursing care competence for exercise for fall prevention for health behaviors patient self-management

669

concepts enactive attainment environment and policies, evaluation of Function-Focused Care in Assisted Living intervention key terms physiological feedback relationships sources of self efficacy judgement verbal persuasion vicarious experience

Self-identity Self-reports Sense of coherence (SOC) scale Sensitivity Significance Situational factors Situational influences Situation-specific theories

examples Social-cognitive theory Social comfort Social contact analysis Social ecological model (SEM) Socialization of child Social network Social persuasions Social support theory

applications in practice in research

challenges to development and research definition of

concepts in health and historical background of measures of motivation for negative nursing assessment andinterventions perceptions

670

physical activity, promotion of timing in variables, influencing variations in

Sociocultural comfort Somatic and emotional states Spectator Spirit Spiritual care Spiritual care in nursing practice (SCiNP)

application in practice theory in research theory

decision, to engage/not engage empirical development historical background immediate emotional response instruments in empirical testing intervention key terms patient cue search for meaning spiritual memory formation

Spiritual intervention Spirituality Spiritual memory formation Spiritual well-being Stability Stranger, nurse role as Strengths-based research Stress-buffering model Stressor Stuifbergen structural model Surrogate, nurse role as Swanson's caring theory Symptom experience in time model (SET) Symptom Management Model (SMM) Synergy Model

description of assumption of model

671

nursing education nursing practice research theoretical concepts, definition of

historical background on key terms in nurse characteristics in patient characteristics in in undergraduate education use of

Systems thinking

T Tautology Teacher, nurse role as Teleology Terminology and attributes of resilience Theoretical linkages Theories of nursing

borrowing in classifications

purposes in sources

controversy uses

Theory analysis

definition by early authors recent approaches

application in education and clinical practice evaluation and model development

Theory development components in

concepts propositions

definition history

672

process sources

Theory evaluation Barnum's recommendations definition Fawcett's recommendations key terms Kolcaba's recommendations Meleis' recommendations

Theory of Caring applications

in practice in research

caring in definitions of theory concepts environment in health in historical background on key terms in nursing in persons, definition of philosophical foundation theoretical assumtions on theory application in education and clinical practice theory development

Theory of Chronic Sorrow examples of external management of historical background internal management key terms middle range theory NCRCS chronic sorrow instrument development research applications trigger events

Theory of Interpersonal Relations assumptions in definitions of theory concepts descriptions of description with propositional statements

673

environment in examples of research health in historical background on key terms in nursing in nursing methods to understand interpersonal processes

communication observation practice recording research theory and model development

patient in persons in phases

of exploitation of identification of orientation of resolution

philosophical foundations of psychobiological experiences psychological tasks

Theory of pain. See under See under Pain (balance between analgesia and side effects)

Theory of Planned Behavior (TPB) application of description of

Theory of Symptom Management (TSM) Theory of Unpleasant Symptoms (TOUS)

description historical background instruments in empirical testing key terms models expanding/modifying

Armstrong model of symptom experience Symptoms Experience in Time Model

symptoms, assessment of Thermal Comfort Questionnaire Transcendence

674

Transtheoretical Model (TTM) application of description of theory

Trigger events

U Unconditional acceptance Undergraduate education, Synergy Model in Unexplained discomfort/anxiety Unitary–transformative paradigms Unmet needs Unpleasant symptoms Urinary Incontinence and Frequency Comfort Questionnaire (UIFCQ) Utility

V Validation Variable-focused approaches Variable-focused research models (resilience) Verbal persuasion Verbal rating scales Vertical relationship Vicarious experience Visual Analog Scale Vulnerability Vulnerable Elders Survey (VES-13)

W Whole-body systematic relaxation technique Wilson and Cleary model

675

Table of Contents

Title 3 Copyright 5 Dedication 7 Contributors to the Fourth Edition 8 Preface 20 Acknowledgments 24 Contents 25 PART I Overview of Theory 31

1 Introduction to the Nature of Nursing Knowledge 32 Philosophy 39 Metaparadigm and Paradigms 43 Conceptual Models 54 Theory: General Issues 59 Grand Theory 74 Middle Range Theory 75 Practice Theory/Micro Theory/Situation-Specific Theory 84 Summary 90

2 Analysis, Evaluation, and Selection of a Middle Range Nursing Theory

105

Historical Background 108 Theory Analysis 109 Theory Evaluation 114 Selecting a Theory for Nursing Research 123 Middle Range Theory Evaluation Process 125

Part II Middle Range Theories: Physiological 130 3 Pain: A Balance Between Analgesia and Side Effects 131

Historical Background 133 Definition of Theory Concepts 135 Description of the Theory of Pain: A Balance Between Analgesia and Side Effects

140

676

Applications of the Theory 142 Use of the Theory in Practice 154 Summary 157

4 Unpleasant Symptoms 168 Historical Background 169 The Theory of Unpleasant Symptoms 170 Description of the Theory of Unpleasant Symptoms 171 Models That Expand or Modify the Theory of Unpleasant Symptoms

176

Assessment of Symptoms 179 Instruments Used in Empirical Testing 180 Summary 182

Part III Middle Range Theories: Psychological 189 5 Self-Efficacy 190

Historical Background 191 Definition of Theory Concepts 192 Relationships Among the Concepts: The Mode 196 Application of the Theory in Research 196 Application of the Theory in Practice 206 Summary 210

6 Chronic Sorrow 219 Historical Background 220 Current Research on Chronic Sorrow 221 Middle Range Nursing Theory of Chronic Sorrow 222 Research Applications of Chronic Sorrow 227 NCRCS Chronic Sorrow Instrument Development 229 Summary 234

7 Spiritual Care in Nursing Practice (SCiNP) 241 Historical Background 242 Empirical Development of the Spiritual Care in Nursing Practice Theory

244

Definition of Theory Concepts 245 Instruments Used in Empirical Testing 248 Application of the Theory in Practice 250

677

Application of the Theory in Research 254 Summary 258

Part IV Middle Range Theories: Social 263 8 Social Support 264

Historical Background 265 Definition of Theory Concepts 266 Application of the Theory in Practice 277 Application of the Theory in Research 280 Challenges to Social Support Theory Development and Research

286

Summary 289 9 Caring 300

Historical Background 301 Theory Development 302 Definitions of Theory Concepts 304 Description of the Theory of Caring 307 Application of the Theory in Research 309 Application of the Theory in Practice 313 Summary 316

10 Interpersonal Relations 322 Historical Background 324 Definitions of Theory Concepts 326 Description of Theory of Interpersonal Relations 328 Applications of the Theory: Research 341 Applications of the Theory: Practice 347 Applications of the Theory: Theory and Model Development 351 Summary 351

11 Attachment 360 Historical Background 361 Description of Attachment Theory 361 Definition of Key Concepts 363 Internal Working Models 363 Patterns of Attachment 364 Attachment as a Basic Need 366

678

Attachment and Care 367 Attachment and Health 368 Development and Change 369 Applications of Attachment Theory: Research 370 Applications of Theory: Practice 374 Further Research 378 Summary 379

Part V Middle Range Theories: Integrative 387 12 Modeling and Role-Modeling 388

Historical Background 391 Expanded Definitions of Modeling and Role-Modeling Concepts

392

Description of the Theory of Modeling and Role-Modeling 401 Applications of the Theory in Research 405 Instruments Used in Empirical Testing 412 Application of the Theory in Practice 413 Outcome 415 Summary 419

13 Comfort 429 Historical Background 431 Definitions of Theory Concepts 432 Description of Theory: Major Components and Their Relationships

435

Research Applications for the Theory of Comfort 442 Instruments Used in Empirical Testing 449 Summary 455

14 Health-Related Quality of Life 459 Historical Background 460 Definition of Theory Concepts 461 Description of the Theory of Quality of Life and Health- Related Quality of Life

463

Application of the Theory in Research 468 Instruments Used in Empirical Testing 470 Health-Related Quality of Life as an Outcome Measure in Nursing

474

679

Summary 477 15 Health Promotion 485

Historical Background 487 Pender's Definition of Health 488 Description of the Health Promotion Model 490 Implications of the Model for Clinical Practice 494 Summary 502

16 Deliberative Nursing Process 506 Historical Background 508 Definition of Theory Concepts 512 Description of the Theory of Deliberative Nursing Process 520 Applications of the Theory 523 Instruments Used in Empirical Testing 536 Conclusion 538 Summary 540

17 Resilience 550 Historical Background and Current Perspectives 552 Definition of Resilience and Concepts 553 Description of Resilience: the Theory 564 Application of a Theory: The Resilience in Illness Model 569 Instruments Used in Empirical Testing of Resilience 579 Summary 580

18 Planned Change 590 Historical Background 592 Definition of Theory Concepts 593 The Health Belief Model 593 Theory of Planned Behavior 597 Transtheoretical Model 600 Organizational Change Theories 604 Summary 611

19 The AACN Synergy Model 617 Historical Background 618 Description of the Theory of Synergy Model 619 Use of the Theory in a System 633

680

Summary 636 Appendix Instruments 639

Burke/Eakes Chronic Sorrow Assessment Tool© 639 General Comfort Questionnaire 644 Comfort Behaviors Checklist 646 Scoring of the Behaviors Checklist 647 Pediatric Asthma Quality of Life Questionnaire With Standardized Activities (PAQLQ[S])

649

Index 650

681

Title
Copyright
Dedication
Contributors to the Fourth Edition
Preface
Acknowledgments
Contents
PART I Overview of Theory

1 Introduction to the Nature of Nursing Knowledge

Philosophy
Metaparadigm and Paradigms
Conceptual Models
Theory: General Issues
Grand Theory
Middle Range Theory
Practice Theory/Micro Theory/Situation-Specific Theory
Summary

2 Analysis, Evaluation, and Selection of a Middle Range Nursing Theory

Historical Background
Theory Analysis
Theory Evaluation
Selecting a Theory for Nursing Research
Middle Range Theory Evaluation Process

Part II Middle Range Theories: Physiological

3 Pain: A Balance Between Analgesia and Side Effects

Historical Background
Definition of Theory Concepts
Description of the Theory of Pain: A Balance Between Analgesia and Side Effects
Applications of the Theory
Use of the Theory in Practice
Summary

4 Unpleasant Symptoms

Historical Background
The Theory of Unpleasant Symptoms
Description of the Theory of Unpleasant Symptoms
Models That Expand or Modify the Theory of Unpleasant Symptoms
Assessment of Symptoms
Instruments Used in Empirical Testing
Summary

Part III Middle Range Theories: Psychological

5 Self-Efficacy

Historical Background
Definition of Theory Concepts
Relationships Among the Concepts: The Mode
Application of the Theory in Research
Application of the Theory in Practice
Summary

6 Chronic Sorrow

Historical Background
Current Research on Chronic Sorrow
Middle Range Nursing Theory of Chronic Sorrow
Research Applications of Chronic Sorrow
NCRCS Chronic Sorrow Instrument Development
Summary

7 Spiritual Care in Nursing Practice (SCiNP)

Historical Background
Empirical Development of the Spiritual Care in Nursing Practice Theory
Definition of Theory Concepts
Instruments Used in Empirical Testing
Application of the Theory in Practice
Application of the Theory in Research
Summary

Part IV Middle Range Theories: Social

8 Social Support

Historical Background
Definition of Theory Concepts
Application of the Theory in Practice
Application of the Theory in Research
Challenges to Social Support Theory Development and Research
Summary

9 Caring

Historical Background
Theory Development
Definitions of Theory Concepts
Description of the Theory of Caring
Application of the Theory in Research
Application of the Theory in Practice
Summary

10 Interpersonal Relations

Historical Background
Definitions of Theory Concepts
Description of Theory of Interpersonal Relations
Applications of the Theory: Research
Applications of the Theory: Practice
Applications of the Theory: Theory and Model Development
Summary

11 Attachment

Historical Background
Description of Attachment Theory
Definition of Key Concepts
Internal Working Models
Patterns of Attachment
Attachment as a Basic Need
Attachment and Care
Attachment and Health
Development and Change
Applications of Attachment Theory: Research
Applications of Theory: Practice
Further Research
Summary

Part V Middle Range Theories: Integrative

12 Modeling and Role-Modeling

Historical Background
Expanded Definitions of Modeling and Role-Modeling Concepts
Description of the Theory of Modeling and Role-Modeling
Applications of the Theory in Research
Instruments Used in Empirical Testing
Application of the Theory in Practice
Outcome
Summary

13 Comfort

Historical Background
Definitions of Theory Concepts
Description of Theory: Major Components and Their Relationships
Research Applications for the Theory of Comfort
Instruments Used in Empirical Testing
Summary

14 Health-Related Quality of Life

Historical Background
Definition of Theory Concepts
Description of the Theory of Quality of Life and Health-Related Quality of Life
Application of the Theory in Research
Instruments Used in Empirical Testing
Health-Related Quality of Life as an Outcome Measure in Nursing
Summary

15 Health Promotion

Historical Background
Pender's Definition of Health
Description of the Health Promotion Model
Implications of the Model for Clinical Practice
Summary

16 Deliberative Nursing Process

Historical Background
Definition of Theory Concepts
Description of the Theory of Deliberative Nursing Process
Applications of the Theory
Instruments Used in Empirical Testing
Conclusion
Summary

17 Resilience

Historical Background and Current Perspectives
Definition of Resilience and Concepts
Description of Resilience: the Theory
Application of a Theory: The Resilience in Illness Model
Instruments Used in Empirical Testing of Resilience
Summary

18 Planned Change

Historical Background
Definition of Theory Concepts
The Health Belief Model
Theory of Planned Behavior
Transtheoretical Model
Organizational Change Theories
Summary

19 The AACN Synergy Model

Historical Background
Description of the Theory of Synergy Model
Use of the Theory in a System
Summary

Appendix Instruments

General Comfort Questionnaire
Comfort Behaviors Checklist
Scoring of the Behaviors Checklist
Pediatric Asthma Quality of Life Questionnaire With Standardized Activities (PAQLQ[S])

Index